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TABLE OF CONTENTS
ADMINISTRATIVE INFORMATION Page
! Welcome to Pediatrics! !!!!!!!!!!!!!!!!!!!!!.4
! McMaster Pediatrics Contact Information !!!!!!!!!!!!!..5
! Paging, RTAS Information !!!!!!!!!!!!!!!!!!!!7
! McMaster CTU 1/2 Pediatrics Expectations and Weekly Schedule!! ..8
! Allied Health Contact Numbers!!!!!!!!!!!!!!!!!!12
! Resources: Handbooks, PDA, Websites !!!!!!!!!!!!!..14
! Dictation Instructions !!!!!!!!!!!!!!!!!!!!!... 18
! Pediatrics Staff Dictation Codes and Pagers !!!!!!!!!!!.. 19
PEDIATRICS AT ST. JOSEPHS HEALTHCARE
! SJH Pediatrics Contact Information, Paging, Door Codes, Library!!.. 26
! SJH CTU 4 Expectations and Weekly Schedule !!!!!!!!!! 27
! Accommodation Services, On-call, Dictating!!!!!!!!!!!... 30
! SJH Instructions for Listening to Dictated Reports !!!!!!!!.... 33
PEDIATRIC INFORMATION
! History & Physical Examination Outline !!!!!!!!!!!!!... 34
! pGALS-A Screening Examination of the MSK system!!!!!!!! 41
! Growth Charts!!!!!!!!!!!!!!!!!!!!!!!!! 48
! Birth Weight Conversion Chart (lbs/oz " kg)!!!!!!!!!!!.. 58
! Adolescent History !!!!!!!!!!!.!!!!!!!!!!!. 59
! Admission Orders !!!!!!!!!!!!!!!!!!!!!!! 62
! Progress Note Template Pediatrics !...!!!!!!!!!!!!! 63
! Documentation !!!!!!!!!!!!!!!!!!!!!!!!64
! Mandatory Reporting of Child Abuse!!!!!!!!!!!!!!.. 66
! Discharge Summary Template Pediatrics !!!!!!!!!!!! 67
! Fluids & Electrolytes !!!!!!!!!!!!!!!!!!!!!.... 69
! Developmental Milestones !!!!!!!!!!!!!!!!!!!. 78
! Immunization Schedule !!!!!!!!!!!!!!!!!!!!.. 81
NEONATOLOGY 84
! St Joes common terms and definitions!!!!!!!!!!!!!!..85
! Progress Note Template Neonatal !!!!!!!!!!!!!!!87
! Discharge Summary Template NICU / Level 2 Nursery !!!!!!. 88
! Neonatal Resuscitation Algorithm !!!!!!!!!!!!!!!!. 92
! Neonatal Resuscitation Drugs !!!!!!!!!!!!!!!!!... 93
! Neonatal Nutrition Guidelines " Enteral !!!!!!!!!!!!!. 94
" TPN !!!!!!!!!!!!!!.
" Vitamins and Minerals !!!!!!..
! Prevention of Perinatal Group B Streptococcal Disease !!!!...!! 103
! Hypoglycemia Guidelines for At-Risk Newborns !!!!!.!!!!.. 105
! Hyperbilirubinemia (Jaundice) In Newborn Infants " 35 Weeks !!!.. 112
! Phototherapy Guidelines for < 35weeks or < 2500 grams!!!!!!..130
! Management of Hypernatremia in a Breastfed Infant!!!!!!!!. 132
FORMULARY 133
! Abbreviation Guidelines HHSC !!!!!!!!!!!!!!!!.. 134
! Safer Order Writing !!!!!!!!!!!!!!!!....................... 136
! Antibacterials !!!!!!!!!!!!!!!!!!!!!!!!! 137
! Pediatric Formulary !!!!!!!!!!!!!!!!!!!!!.. 151
! Opiod Analgesic Equivalence!!!!!!!!!!!!!!!!!!. 170
Table of Contents Continued.
! Systemic Steroid equivalence!!!!!!!!!!!!!!!!!! 171
! Antibiotic Guide For Common Pediatric Infections!!!!!!!!! 172
! PPI comparison chart!!!!!!!!!!!!!!!!!!!!!.. 174
! Pediatric Nutrition Formulary.............................................................. 175
PEDIATRIC EMERGENCY MEDICINE!!!!!!!!!!!!!!! 178
! PALS Algorithms !!!!!!!!!!!!!!!!!!!!!!!.. 179
! PALS Algorithm Medications !!!!!!!!!!!!!!!!......... 182
! Status Epilepticus Algorithm !!!!!!!!!!!!!!!!!!.. 184
! Diabetic Ketoacidosis Guidelines !!!!!!!!!!!!!.. !!... 188
Pediatric Vital Signs and Glasgow Coma Scale (GCS) !!!!!!!!!190
WELCOME TO MacPeds!
This handbook was designed for the large number of residents from a
variety of disciplines that rotate through pediatrics during their first year
of training. It may also be helpful for clinical clerks during their time on
the pediatric wards, as well as for pediatric residents and elective
students.
Hopefully this demystifies some of the pediatric specific logistics, and
gives a few practical suggestions for drug dosages and fluid
requirements. This is intended only to act as a guideline for general
pediatrics use, and some drugs, doses, indications and monitoring
requirements may differ in individual situations. I would like to thank
!"#$%& (%)*+& and Melani Sung for compiling and editing the pediatric
formulary section and Lori Chessell and Connie Stuart for compiling the
Neonatal Nutrition Section.
The Drug Formulary in this book is intended for pediatric patients only.
For neonatal drugs to be used in the neonatal nurseries please refer to the
neonatal drug book in the neonatal nurseries.
I would very much appreciate any feedback, suggestions or
contributions emailed to ladhanim@mcmaster.ca
Sincerely,
Moyez B. Ladhani
Editor
Permission to copy and distribute this document is granted provided that (1) the
copyright and permission notices appear on all reproductions; (2) use of the
document is for non-commercial, educational, and scientific purposes only; and (3)
the document is not modified in any way.
MacPeds Survival Guide 14-15 4
McMaster PEDIATRICS CONTACT INFORMATION
Wards
3B 72980
3C North 76345, 76344
3CSouth 73388, 76972
L2N 73753
NICU 76147
L & D 75050
4C Nursery 76354
PCCU 72610, 75692
PCCU SD
Eating Disorder Unit 73289
Clinical
3F clinic 73984, 78517
2G clinic 78517
2Q clinic 75094, 75095
OR Reception 75645
PACU 75653
Short Stay 75564
Radiology 75279
MRI 75059
CT scan 73728-room
75279-reception
76672-reporting
Ultrasound 75316, 75319
EEG 4U 75027
ECHO 2G 73974
GI pH probe 75350
Labs
Stat Lab 76303
Chemistry 75022
Blood Bank 76281
Coagulation 76288
Microbiology 46175
Pathology 76419
Administration
Paging 76443
Admitting 75100
Bed Booking 75106
Health Records 75111
Computer Support 43000
Appointments 75051
Info Desk 75266
Security 76444
Room bookings 22382
MacPeds Survival Guide 14-15 5
Program Assistants
Postgraduates: Shirley Ferguson 28023
peded@mcmaster.ca
Adriana Flaiani 21931
flaiani@mcmaster.ca
Sandy Murray 21882
samurra@mcmaster.ca
Undergrad (clerks) Kim Babin 21954
pedclrk@mcmaster.ca
BCT residents: Colleen Willson 26660
willsoc@mcmaster.ca
Family Med residents: Jennifer Frid 76024
frid@mcmaster.ca
Wendy Milburn 905-575-1744 x203
milburn@mcmaster.ca
CTU
Skye Levely 75639
levelys@mcmaster.ca
Chief Residents Pediatrics
macpedschiefs@gmail.com
MacPeds Survival Guide 14-15 6
PAGING
To page someone from within the hospital:
1. dial 87
2. enter persons pager number (4 digits)
3. enter call-back extension (5 digits)
4. enter priority code (! * then 1 for CODE/STAT, 2 for
ROUTINE, 3 for ANYTIME, 4 denotes PHYSICIAN paging)
If you dont know their pager #, wish to leave a typed message or
to wait on an outside line: call x76443
To inactivate/activate your own pager:
1. dial 87
2. enter your own pager #
3. dial 08
RTAS (Rapid Telephone Access System)
For retrieval of dictated radiology reports not yet typed on Meditech
Internal access x75077
To access from outside (905) 521-5077
Security code 4123#
Patients ID # (9 digits)
1 stop report
2 resume play
3 rewind
4 slow down speed
5 disconnect from system
6 speed up
8 next report
0 go to start of report
MacPeds Survival Guide 14-15 7
Division of General Pediatrics CTU 1, CTU 2, Weekly Schedule
Handover:
Handover is to take place from 0715-0745 hrs. It is therefore important to complete
a succinct handover within the allotted 30 minutes. The senior residents will meet
with the charge nurses from 3B/3C/3Yto review potential discharges at 9:15am.
Discharge Rounds:
Discharge rounds will be a brief meeting with the attending paediatrician, and Senior
Pediatric Residents. Patients that can go home will be identified at this time and
discharges for these patients should occur promptly. Discharge planning should
always be occurring and the team should discuss patients that could potentially go
home the night before. This would then be the time to ensure that if those patients are
ready that the patients are discharged.
See Patients:
During this time the team will see their assigned patients. The chart and nursing
notes should be reviewed to identify any issues that have arisen over night. The
patient should be seen and examined. All lab work and radiological procedures that
are pending should be reviewed. The house staff should then come up with a plan for
the day and be ready to present that patient during ward rounds. It is not necessary
that full notes be written at this time, as there will be time allotted for that later in the
day.
Ward Rounds:
During ward rounds the attending paediatrician, with/without Senior Resident, and
house staff will round on patients for their team. These are work rounds. All efforts
should be made to go bedside to bedside to ensure that all patients are rounded on.
Some spontaneous teaching during rounds and at the bedside can occur during this
time, however there is allotted time for that later in the day.
Case Based Learning
There will be 10 modules that the learners should complete during their stay on the
CTU over a one-month period. The senior resident will be responsible to assign the
cases to be discussed. The team should read the articles provided and work on the
objectives prior to the discussion with the senior and other learners. The attending is
encouraged to play a supervisory role during the discussions.
MacPeds Survival Guide 14-15 8
Patient Care:
During this time residents will follow through with decisions made during ward
rounds. They will finish charting on patients. This is also the time for them to get
dictations done and to complete face sheets.
Teaching Sessions:
There are various teaching sessions throughout most days on the CTU. Please refer to
the CTU teaching schedule for locations this will be posted online as well as on the
wards.
Monday morning from 08:00-09:00 will be Division of General Paediatric
Rounds.
Mondays from 15:00 to 16:00 there will be Specialty teaching session. It is
the goal during this time to get various specialties to come in and teach around
patients that are on the ward.
Bedside case teaching. The individual teams will do these as time permits.
Tuesdays from 08:00 to 09:00 Teaching for all learners, except third
Tuesday, which is for Pediatric residents only.
Wednesdays 4
th
Wednesday of the month will be Peds Cardiology teaching
Heart to Heart which is from 08:00-09:00
Wednesday is Academic Half Day for pediatric residents.
Thursdays from 08:00 to 09:00 Pediatric Grand Rounds
Second Thursday starting at 13:30, will be Simulation teaching, refer to the
monthly schedule for details.
Thursdays from 15:00 to 16:00: There will be radiology teaching once a
month and possibly other teaching session booked.
Friday 08:00-09:00, can be used for the Case Based Learning modules.
Nurses and other health care professionals are welcome to attend these rounds.
Evaluations:
Time is left in the schedule for evaluations. This would be the time to give
residents mid-way evaluations, as well as end of rotation evaluations.
Handover 1630 hrs:
Handover will occur to the on-call team. Refer to the handover document for
further details.
MacPeds Survival Guide 14-15 9
Orientation:
At the beginning of each month the attending should meet with their team
members to review the objectives, expectation and schedule of the rotation. The
senior resident may have valuable input during this time. Residents should also be
directed to the online orientation module.
Multi-Disciplinary Rounds:
Team 1 and 2 will occur on Tuesdays. Team 1 will be from 1300-1330; Team 2
will be from 1330-1400.
MacPeds Survival Guide 14-15 10
Division of General Pediatrics
CTU 1 and 2 Weekly Schedule
Monday Tuesday Wednesday Thursday Friday
7:15-7:45 Handover Handover Handover Handover Handover
8:00-9:00
Division of
General
Pediatrics
Rounds
4E20
Teaching *
except third
Tuesday
LCC for
Peds
residents
only
Week 4:
Heart to
Heart
(08:00-
09:00)
Grand
Rounds
MDCL 3020
Case Based
Learning
9:00-10:30 See Patients See Patients See Patients See Patients See Patients
10:30-12:00
Ward
Rounds
Ward
Rounds
Ward
Rounds
Ward
Rounds
Ward
Rounds
12:00-13:00 Lunch Lunch Lunch Lunch Lunch
13:00-15:00
Patient
Care
*MDR 1& 2 Patient
Care/AHD
*MDR 3 Patient
Care Patient Care Patient Care
15:00-16:00
Specialty
Teaching
AHD
Teaching
Sessions
16:00-16:30 Evaluations Evaluations AHD Evaluations Evaluations
16:30-17:00 Handover Handover Handover Handover Handover
Please refer to attached document for details of each of the above.
*MDR = Multidisciplinary Rounds.
The detailed monthly schedule for this can be found at
www.macpeds.com
MacPeds Survival Guide 14-15 11
ALLIED HEALTH CONTACT NUMBERS/PAGERS
SPECIALTY NAME PAGER Phone
RT Ward General Pager 1607
OT Deb Gjertsen 1177 73565
OT Kate Dobson-Brown 1240 73394
OT Trish Case 1885 73733
SLP Sara Webster 5082 73726
PT Weekend 1148
PT Sarah Fairfield 1148 76549
PT Jillian McJannet 1029 76549
PT Barb Pollock 4317 76549
CCAC Nicole Biba 76599
CCAC Ann Rush 1092 72840
Child Life After hours/Weekends 1225
Child Life Margaret Karek 1225 76129
Child Life Laura Perkin 4086 76129
Child Life Maria Restivo 4087 76129
Child Life Lora Zimmerman 4092 76129
Dietitian Helena Pelletier 1279 73562
Dietitian Lisa Talone 1513 73562
Dietetic Assistant Allison Pottinger 1074 73159
Pharmacist Nicole Clarke 1423 76356
Pharmacy
Technician
Carrie Morrell 1099 76356
IV Nurse 1007
Wound Care
Nancy Trapasso 5150 76100
MacPeds Survival Guide 14-15 12
Nurse
Social Work Carol Ann OToole 1193 73714
Social Work Bill Ratz 1039 76339
Acute Nurse Care
Practitioner
Rose-Frances Clause
1934
73035
Respiratory Home
Care Coordinator
Jeannie Kelso
1042
73650
Clinical Nurse
Specialist
Joanne Dix
1409
76548
Team 1 Pager 5301
Team 2 Pager 5302
Team 3 Pager 5303
Senior Pediatric
Resident
1645
Pediatric ICU
Resident
1000
MacPeds Survival Guide 14-15 13
RESOURCES
Handbooks/Pocketbooks:
Hospital for Sick Children Handbook (11
th
ed, 2010).
Harriet Lane Handbook (1999): John Hopkins Hospital, Dept
of Pediatrics.
Pediatrics on Call
Pediatric Drug Dosage Handbook (on most wards)
Sickkids Drug Handbook and Formulary
Texts:
Nelson Textbook of Pediatrics (19th ed): Behrman R.E. and
R.M. Kliegman.
Rudolphs Fundamentals of Pediatrics (3
rd
ed, 2002):
Rudolph, A.M. et al.
Pediatric Clinical Clerkship Guide
Clinical Skills:
Pediatric Clinical Skills (3
rd
ed): Richard A. Goldbloom.
Journals (all accessible via e-Resources at McMaster
Libraries)
Pediatrics In Review. Monthly publication by AAP (American
Academy of Pediatrics), consisting of review articles and
case presentations
NeoReviews. Monthly publication by AAP, featuring
excellent review articles of common neonatal conditions
Journal of Pediatric & Child Health. Monthly publication of
CPS (Canadian Pediatric Society).
MacPeds Survival Guide 14-15 14
WEBSITES
McMaster Pediatrics Residency Program
http://www.macpeds.com
Our residency program site that includes staff & resident presentations,
subspecialty orientation materials, policy statements and our favorite links.
Canadian Pediatric Society - Position Statements
http://www.cps.ca/en/documents
The main site also directs you to their journal (Pediatrics and Child Health)
and a separate site for information for parents (Caring for Kids).
American Academy of Pediatrics (AAP)
http://pediatrics.aappublications.org/site/aappolicy/index.xhtml
The American equivalent of CPS, which has an expansive collection of
practice guidelines and policy statements that are widely quoted.
CDC Growth charts
http://www.cdc.gov/growthcharts/
WHO Growth charts
http://www.who.int/childgrowth/standards/en/
Training Modules for WHO Growth Charts
http://www.dietitians.ca/Knowledge-Center/Live-Events/Online-
Courses/WHO-Growth-Chart-Training.aspx
SOGC Guidelines (Society of Obstetricians and
Gynecologists of Canada)
http://sogc.org/clinical-practice-guidelines/
MacPeds Survival Guide 14-15 15
Evidence-based guidelines created by the SOGC, as indexed by topic
area. Some of these are quite helpful in Level 2 Nursery and other
newborn settings. Many others are quite helpful during your obs/gyn
rotation!
Stanford School of Medicine Newborn Nursery Photo Gallery
http://newborns.stanford.edu/PhotoGallery/GalleryIndex.html
Alphabetically organized collection of photographs of common neonatal
conditions and dermatology
CanChild-Centre for childhood disability research
http://www.canchild.ca/en/
MORE WEBSITES !
Motherisk Program
http://www.motherisk.org/
A comprehensive program for evidence-based online information about the
safety or risk of drugs, chemicals and disease during pregnancy and
lactation based at Hospital for Sick Children.
National Advisory Council on Immunization (NACI)
http://www.phac-aspc.gc.ca/naci-ccni/
A program of the Canadian Public Health Association for educating parents
and families, as well as health care professionals about the benefits and
guidelines regarding childhood immunizations.
Canadian Institute of Child Health (CICH)
http://www.cich.ca/index_eng.html
As their mission statement states Dedicated to promoting and protecting
the health, well-being and rights of all children and youth through
monitoring, education and advocacy.
MacPeds Survival Guide 14-15 16
PHONE APPS/PDA
Pediatrics on call useful for common pediatric conditions
Pediatstat quick access pediatric resuscitation information
Pediatric EKG common pediatric ECG findings
Epocrates (http://www.epocrates.com) free, drug database
HSC Handbook, Harriet Lane, The 5-minute pediatric consult both
available on PDA and Skyscape
OTHER LINKS
Hematology Oncology:
http://www.pedsoncologyeducation.com/
Neurology Exams:
http://library.med.utah.edu/pedineurologicexam/html/home_exam.html
Cardiology:
http://depts.washington.edu/physdx/heart/demo.html
http://www.wilkes.med.ucla.edu/Physiology.htm
MacPeds Survival Guide 14-15 17
DICTATIONS Hamilton Health Sciences Corporation
x5000 to enter, (905) 575-2550 externally
Enter Author ID (#)
Enter site (#)
11. General
12. Henderson
13. MUMC
14. Chedoke
Enter Report Type (#)
21. Consultation
22. Discharge
3. Operative Report
4. Pre-op History & Physical
25. Clinic Note
Enter Chart Number (#) the ID # after the M
Enter Patient Type (#)
1. Inpatient
2. Outpatient
3. ER
4. Child & Family
Press 2 to dictate, *5 to disconnect
1. Hold
2. Pause/Continue
3. Skipback/Play
4. Fast Forward (44 to move to end)
5. Disconnect
6. Prioritize
7. Rewind (77 rewind to beginning)
8. End Report
For each report:
- your name, patient name (spelling if difficult)
- chart number, work type, copies to (FD, pediatrician, consultants, MRP, etc)
MacPeds Survival Guide 14-15 18
PEDIATRIC STAFF PAGERS AND OFFICE NUMBERS
General
Pediatrics
Pager Number
Office
Number
Babic, B 7638 664-9913 General Pediatrics
Cheung, W 7522 523-1209 General Pediatrics
Chitayat, S 7349 523-6766 General Pediatrics
Ernst, C 3339 522-8915 General Pediatrics
Federici, J 7347 333-5437 General Pediatrics
Fitzpatrick, K 523-3167 575-0611 General Pediatrics
Gambarotto, K 572-8681 575-0611 General Pediatrics
Giglia, L 7536 523-6766 General Pediatrics
Hallett, K 2089 664-9992 General Pediatrics
Hunter, A 7561 575-0611 General Pediatrics
Ladhani, M 2040 x75639 General Pediatrics
Latchman, A 2555 x76340 General Pediatrics
Lim, A 3499 X76340 General Pediatrics
MacNay, R 2031 523-1209 General Pediatrics
Orovec, N 76443-paging 664-9992 General Pediatrics
O'Toole, F 524-7609 575-0611 General Pediatrics
Roy, M 2023 x75639 General Pediatrics
Seigel, S 3008 628-0054 General Pediatrics
MacPeds Survival Guide 14-15 19
Shbash, I 7570 575-0611 General Pediatrics
Wahi, G 2315 x76340 General Pediatrics
Sub-Specialist Pager Office
Number
Specialty
NICU
El Gouhary, E 2009 X73588 Neonatology
El Helou, S 2560 x73490 Neonatology
Fusch, C 2045 x75721 Neonatology
Gani, AW 2003 x73689 Neonatology
Marrin, M 2705 x73490 Neonatology
Pugh, E 6437 x76342 Neonatology
Twiss, J 2113 x73591 Neonatology
Samiee-
Zafarghandy, S
2565 x73568 Neonatology
Shah, J 1502 x76342 Neonatology
Shivananda, S 2403 x73490 Neonatology
Williams, C 2128 x 73502 Neonatology
Sub-Specialist
Surgery
Pager Office
Number
Specialty
Ayeni, F 2104 x73532 or
x75094
Ortho Surgery
Ajani, F 2206 X75237 Neurosurgery
MacPeds Survival Guide 14-15 20
Bailey, K 2766 x73550 or
x75094 (2Q)
General Surgery
Bain, J 2628 x73222 or
x78520
Plastic Surgery
Braga, L 76443 - paging x73777 or
x78519
Urology
Burrow, S 2133 x73177 or
x75094
Ortho Surgery
Cameron, B 76443 - paging x75231 or
x75094 (2Q)
General Surgery
Choi, M 2060 X73550 or
X78520
Plastic Surgery
DeMaria, J 76443- paging x73777 or
x78519
Urology
Fitzgerald, P 76443 - paging x75231 or
x75094 (2Q)
General Surgery
Flageole, H 76443 - paging x75244 or
x75094 (2Q)
General Surgery
Korman, B 2600 x75246 or
x75051
ENT
MacLean, J 2504 x75246 or
x75051
ENT
Mah, J. 8030 905 575
3600
Ortho Surgery
Missiuna, P. 7907 905 527
9149
Ortho Surgery
MacPeds Survival Guide 14-15 21
Ogilvie, R 76443 - paging 905 304-5818 Ortho Surgery
Peterson, D 2035 x73177 or
x75094
Ortho Surgery
Sabri, K 76443 - paging x73509 or
x72400
Ophthalmology
Singh, S 2577 x75237 or
x75011
Neurosurgery
Shawyer, A. 76443 paging x75231 or
x75094 (2Q)
General Surgery
Strumas, N 76443 - paging x73594 or
x78520
Plastic Surgery
Walton, M 76443- paging x75244 or
x75094 (2Q)
General Surgery
Sub-Specialist Pager Office
Number
Specialty
Almeida,C 76443 - paging x75259 Cardiology
Anchala, K No pager x75155 ER
Arora, S 2066 x75635 Nephrology
Athale, U 2118 x73464 Hem-Onc
Baird, B 7028 x75607 ER
Barr, R 2712 x73428 Hem-Onc
Bassilious, E 2081 x73716 Endocrinology
Batthish, M 76443 - paging X75382 Rheumatology
Belostotsky, V 76443 - paging x75635 Nephrology
MacPeds Survival Guide 14-15 22
Breaky, V 2125 x73428 Hem-Onc
Brill, H 2476 x73455 GI
Callen, D 2038 x75686 Neurology
Carter, T 2644 x73508 Development
Cellucci, T 76443 - paging X75382 Rheumatology
Chan, A 905-521-5030 x73464 Hem-Onc
Choong, K 2865 x76651 PICU
Crocco, A 76443 - paging X75621 ER
Cupido, C 2327 x76610 PICU
Dent, P 3720 x75382 Rheumatology/
Immunology
Dillenburg, R 76443 - paging x75242 Cardiology
Findlay, S 905-972-1091 x75658 Adolescent/Eating
Disorder Unit
Gilleland, J 2065 x75823 PICU
Goldfarb, D 7158 x76947 Infectious Dis.
Gorter, J.W 2531 X26852 Development
Grant, C 2036 x75658 or
x73862
Adolescent/Eating
Disorder Unit
Harman, K 2887 X73504 or
x77210
Development/Cleft
Lip & Palate
Hernandez, A 2645 x75607 ER
Huang, L 2026 x73141 or PICU
MacPeds Survival Guide 14-15 23
x76610
Issenman, R 2768 x75637 GI
Johnson, N 2995 x75658 Adolescent/Eating
Disorder Unit
Kam, A 76443 - paging x75621 ER
Kozenko, M 2106 X76172 Genetics
Kraus de
Camargo, O
76443 - paging x74275 Development
Li, C 2729 x76815 Genetics
Lloyd, R 2684 x76610 PICU
Mahoney, B 2713 X 77345 Development
McAssey, K 76443 - paging x 75702 Endocrinology
Meaney, B 905-317-2807 x75686 Neurology
Mesterman, R 2029 x74393 or
x74275
Neurology
Mondal, T 2039 x75259 Cardiology
Morrison, K 76443 - paging x75702 Endocrinology
Niec, A 2637 x73687 Psych, CAAP
Nowaczyk, M 7207 X73042 Genetics
Parker, M 2073 x76651 PICU
Pernica, J 2092 x76947 Infectious Dis.
Portwine, C 2119 x73464 Hem-Onc
Predescu, D 76443 - paging x75264 Cardiology
MacPeds Survival Guide 14-15 24
Ramachandran
Nair, R
2360 x75613 Neurology
Ratcliffe, E 2059 x73455 GI
Ronen, G 2212 x75393 Neurology
Rosenbaum, P 2742 x26852 Development
Rosenbloom, E 76443 - paging x76038 ER
Samaan, C 76443 - paging x73716 Endocrinology
Scheinemann, K 2077 x73428 Hem-Onc
Sherlock, M 2191 73455 GI
Solano, T N/A 75621 ER
Somani, A 2417 x 75823 PICU
Sulowski, C 76443 - paging x75607 ER
Tarnopolsky, M 2888 x75226 Neuromuscular
Timmons, B N/A x 77615 Exercise
VanderMeulen, J 76443 - paging x73716 Endocrinology
Wyatt, E N/A x75607 ER
MacPeds Survival Guide 14-15 25
ST. JOSEPHS HOSPITAL PEDIATRICS
Hospital Contact Numbers
Auto attendant (905) 522-1155
Switchboard (905) 522-4941
Labour and Delivery 33251, 34157
NICU 36050
3 OBS (Well Babies Nursery) 33314
Paging 33311
Dr Sandi Seigel
Deputy Chief St Joes Clinical
36039
seigels@mcmaster.ca
Dr. Bojana Babic
Education Rep CTU
36039
babi!"#$!$%&'()*!%
Rosie Evered
Program Secretary
36039
)(+()(,#&'-.(&*!%
Paging (33311) and Pagers:
All paging done via switchboard attendant at extension 33311
Resident on-call usually carries pager # 412
Clerk on-call usually carries pager # 410
Page staff pediatrician on-call through paging (33311)
McMaster assigns most pagers, check with program area
If pager needed, sign out daily pagers at Switchboard
Library Services:
2
nd
Floor of Juravinski Tower
Hours: MON, WED, FRI 8:00 AM 6:00 PM
TUES, THURS 8:00 AM 8:00 PM
X33440 or library@stjosham.on.ca
MacPeds Survival Guide 14-15 26
!"#"$"%& %( )*&*+,- .*/",0+"1$ 234 5 678*10,0"%&$
!"#$%&'()
Banuovei is to take place at 8:uu his togethei with staffNP anu iesiuents. 0n
the moinings when theie aie iounus (Nonuay anu Thuisuay) hanuovei shoulu
stait at 7:4S. Weekenu hanuovei is at 8:uu his.
+,-./"(0' 1%2#$-)
Bischaige planning shoulu always be occuiiing anu the team shoulu uiscuss
patients that coulu potentially go home the night befoie. Bischaiges foi these
patients shoulu occui piomptly aftei the hanuovei if patients aie ieauy. This is
paiticulaily impoitant foi the well babies on S0bs anu any anticipateu
uischaiges fiom the nuiseiy.
3'' 4"5,'#5-)
Buiing this time the team will see theii assigneu patients. The chait anu nuising
notes shoulu be ievieweu to iuentify any issues that have aiisen ovei night. The
patient shoulu be seen anu examineu. All lab woik anu iauiological pioceuuies
that aie penuing shoulu be ievieweu. The house staff shoulu then come up with
a plan foi the uay anu be ieauy to piesent that patient uuiing waiu iounus. It is
not necessaiy that full notes be wiitten at this time, as theie will be time allotteu
foi that latei in the uay.
6"($ 1%2#$-)
Buiing waiu iounus the team will iounu on patients. These aie woik iounus.
Some spontaneous teaching uuiing iounus anu at the beusiue can occui uuiing
this time, howevei theie is allotteu time foi that latei in the uay.
4"5,'#5 7"(')
Buiing this time iesiuents will follow thiough with uecisions maue uuiing waiu
iounus. They will finish chaiting on patients. This is also the time foi them to
get uictations uone anu to complete face sheets.
8'"./,#0 3'--,%#-)
Theie aie vaiious teaching sessions thioughout most uays on the CT0. Please
iefei to the CT0 teaching scheuule foi locations - this will be posteu online.
MacPeds Survival Guide 14-15 27
9&":2"5,%#-)
Time is left in the scheuule foi evaluations. This woulu be the time to give
iesiuents miu-way evaluations, as well as enu of iotation evaluations.
!"#$%&'( ;<== /(-)
Banuovei will occui to the on-call team with iesiuents, NP anu staff togethei.
>(,'#5"5,%#)
At the beginning of each month the attenuing shoulu meet with theii team
membeis to ieview the objectives, expectation anu scheuule of the iotation. The
senioi iesiuent may have valuable input uuiing this time.
MacPeds Survival Guide 14-15 28
!"#"$"%& %( )*&*+,- .*/",0+"1$
234 5 6**7-8 91:*/;-*
90< =%$*>:?$ @*,-0:1,+*
@,&/%#*+ ,0 A ,BC 1%BD"&*/ $0,((E F. ,&/ +*$"/*&0G(*--%HC %11;+$ ,0 IC5J ,B
%& +%;&/$ /,8$
Nonuay Tuesuay Weunesuay Thuisuay Fiiuay
8-9
am
BuP iounus Peus iesiuents
teaching fiom
N0NC
Ncmastei
Peus gianu
iounus
.Ncmastei
NIC0 iounus
9-1u
am
See
ptsuischaiges
Staff touches base
with
BANAS0BSL&B
ie consults
NPSPR to meet
at 9 to uiviue up
supeivisoiy
iesponsibility
See
ptsuischaiges
Staff touches base
with BANAS0BS
L&B ie consults
NPSPR to meet
aftei hanuovei to
uiviue up
supeivisoiy
iesponsibility
See
ptsuischaiges
Staff touches base
with
BANAS0BSL&B
ie consults
NPSPR to meet
aftei hanuovei to
uiviue up
supeivisoiy
iesponsibility
See
ptsuischaiges
Staff touches
base with
BANAS0BS
L&B ie
consults
NPSPR to
meet at 9 to
uiviue up
supeivisoiy
iesponsibility
See pts
uischaiges
Staff touches
base with
BANAS0BS
L&B ie
consults
NPSPR to
meet aftei
hanuovei to
uiviue up
supeivisoiy
iesponsibility
1u-12 NIC0 iounus
No non-uigent
inteiiuptions
NIC0 iounus No
non-uigent
inteiiuptions
NIC0 iounus No
non-uigent
inteiiuptions
NBR iounus
NIC0 iounus
No non-uigent
inteiiuptions
NIC0 iounus
No non-
uigent
inteiiuptions
12-1
pm
lunch lunch Lunch lunch Lunch
1-2
pm
finish notessee
consults
finish notessee
consults
Acauemic V uay finish
notessee
consults
finish
notessee
consults
2- 4
pm
Teaching
(CBLjouinal
aiticles) quality
assuiance family
Neetings)
Clinic: 1 leainei
attenus with staff
Acauemic V uay;
may have family
meetings
Clinic: 1
leainei
attenus with
staff
Teaching
(CBLjouinal
aiticles)
quality
assuiance
family
meetings
4-S
pm
Finish woik,
upuate list
Finish woik,
upuate list
Acauemic V uay Finish woik,
upuate list
Finish woik,
upuate list
BuP iounus - Bivision of ueneial Peuiatiics' Rounus - viueoconfeienceu
LIvE to S}B Rm T2Su8 (libiaiy) except 1
st
Nonuay
uianu iounus - Bepaitment of Peuiatiics uianu Rounus - viueoconfeienceu
LIvE to S}B Rm T2Su8 (libiaiy)
NBR - Nultiuisciplinaiy Rounus
MacPeds Survival Guide 14-15 29
Accommodation Services
On-Call Rooms:
Key: sign out from Front Desk/ Switchboard, must be returned by 11:00
AM the next day
Location: 2nd floor Martha Wing, Resident call room # 213
! follow Gold Signs to Father O'Sullivan Research Centre
Additional Key: unlock Washrooms + Showers or Code 2 4 3
Residents Lounge (Microwave & TV): Code 2 4 3
! across from vending machines on 2
nd
floor before call rooms
Problems: communicate to Switchboard or Mike Heenan x32218
Cafeteria Hours:
Charlton Cafeteria
2
nd
Floor, Mary Grace Wing
MON FRI: 7:30 AM 6:30 PM
SAT SUN: Closed
Garden Caf @ CMHS MON FRI: 9:30 AM 10:30 PM
& 11:30 AM 1:30 PM
Tim Horton Daily: 7:00 AM 11:30 PM
Information Services
Clinical Brower Passwords & Training:
Passwords obtained from: Computer Room
5
th
Floor of Mary Grace Wing G507
x32218 for Passwords
Must accept password and confidentiality agreements by signature
For additional information on Clinical Browser or training call:
Shauna Stricker x35286
PACS Passwords & Training:
PACS passwords same as Clinical Browser, except all UPPERCASE
You may change your password once you have logged on
PACS training is only offered at the Monthly Medical Learner Orientation
Sessions. For session dates and times contact:
Diane Larwood 34077
MacPeds Survival Guide 14-15 30
St Joes Dictation System
MacPeds Survival Guide 14-15 31
MacPeds Survival Guide 14-15 32
LISTENING TO DICTATED REPORTS AT
ST JOSEPHS HEALTHCARE
Use telephone to listen to Diagnostic Imaging Reports
that have been dictated but not yet transcribed
Requires Check-In # of your Patients Exam. Found in
Check-In # field (usually beside Patients Name) on
any PACS Workstation
If you are unable to find Check-In # field on the Workstation, then call
Diagnostic Imaging staff for assistance: x33606 or x36009
Instructions
1. DIAL 32078 to access the central dictation system.
2. PRESS the # sign.
It is Important that you PRESS THE # SIGN to LISTEN, because 32078
is also used to DICTATE reports.
3. PRESS 1. Enter Physician Author Dictation ID Number (0995)
4. PRESS 1.
5. Enter Patients 7-digit Check-In #
6. LISTEN to the report
Press 5 to listen to a previous exam report on your patient, if the report
you are hearing is not the one you requested
If you have entered the wrong check-in number or if would like to hear
another report, follow the verbal prompts, Press 1 then repeat Steps 5 &
6
MacPeds Survival Guide 14-15 33
PEDIATRIC HISTORY & PHYSICAL EXAMINATION
HISTORY
Identifying Data:
Name, sex, age (years + months), race, who accompanies child,
significant PMHx
Chief Complaint: in patients or parents words
History of Presenting Illness (HPI):
Open-ended question, and allow parents or child to express their
concerns
Similar HPI details to an adult history
Establish time line: when was your child last well?, what happened
next? etc
Select key symptoms and expand:
colour, character, quantity of vomit etc,
OPQRST of pain, aggravating/relieving factors etc
Always ask about recent exposures to ill contacts family, school
Past Medical History (PMHx):
Significant ongoing medical problems
Prenatal history:
Mothers age, gravida, live births, abortions etc
Planned vs unplanned pregnancy, onset of prenatal care
Complications, smoking, drinking, meds, drug use in pregnancy
Gestational age at birth
Birth history:
Spontaneous vs induced labour, duration, complications
Presentation: breech, vertex, transverse
Interventions required: forceps, vacuum, c-section
Resuscitation required, Apgars, birth weight (conversion chart)
NICU, Level 2 nursery admission, duration
Newborn history:
Common problems: jaundice, poor feeding, difficulty breathing
Hospitalizations and significant accidents
Surgical history
MacPeds Survival Guide 14-15 34
Medications including dose changes, compliance
Allergies list specific reaction
! Immunizations ask specifically about Prevnar, Menjugate, Varivax,
Synagis (if neonate).
PEDIATRIC HISTORY AND PHYSICAL EXAMINATION (Continued)
Feeding History (if relevant):
Breast feeding: exclusively?, duration, frequency
Formula: brand, how is it prepared/diluted, # of feedings/day, quantity
Solids: when started, tolerated, any reactions
Vitamins (especially iron and Vit D): which ones, how often, dose
Present diet: cereals, fruit, vegs, eggs, meat, amt of cows milk
Any difficulties with feeding? Any concerns from primary physician
about poor weight gain?
Developmental Milestones (if relevant):
Have you ever had any concerns about your childs development?
How does child compare with siblings?
Ask about current milestones in each category as appropriate for their
age:
Gross motor
Fine motor, vision
Speech, hearing
Social skills
Use major milestones (walking, first word, toilet training, etc) to
assess previous development (Reference on page 38)
Use Denver II charts etc to assess current stage of development
Social History
Who lives at home? Who are primary caregivers? Parents work
outside the home?
Does the child attend daycare? How many other children? In a
home vs. institution?
Stability of support network: relationship stability, frequent moves,
major events (death in family etc), financial problems, substance
abuse in the home
Has CAS ever been involved?
MacPeds Survival Guide 14-15 35
School adjustment, behaviour problems, habits (nail-biting,
thumbsucking etc), sleep changes
How has this disease affected your child/ your family?
What does your family do for fun? What does your child do for fun?
For an asthma history: smoke, pets, carpets, allergens in the home,
family history of asthma / atopy.
PEDIATRIC HISTORY AND PHYSICAL EXAMINATION (Continued)
Family History:
Are parents both alive and well? How many siblings? Are they
healthy?
Are there any childhood diseases in the family?
Consanguinity are mother and father related in any way?
Relevant family history (3 generations) autoimmune hx in Type I
DM, atopic hx in asthma etc
Draw pedigree if possible for genetic assessment
Review of Systems:
General: feeding, sleeping, growing, energy level
Signs of illness in kids: activity, appetite, attitude (3 As)
HEENT: infections (how often, fever, duration): otitis, nasal discharge,
colds, sore throats, coughs, nosebleeds, swollen glands, coughing or
choking with feeding
Cardio:
Infants: fatigue/sweating during feedings, cyanosis, apneas/bradycardic
episodes
Older kids: syncope, murmurs, palpitations, exercise intolerance
Resp: cough, wheezing, croup, snoring, respiratory infections
GI: appetite, weight gain (growth chart), nausea/vomiting, bowel habits,
abdominal pains
GU: urinary: pain/frequency/urgency, sexually active, menarche/menses,
discharge/pruritis/STDs
MacPeds Survival Guide 14-15 36
MSK: weakness, sensory changes, myalgias, arthralgias, growing pains
Neuro: headaches, seizures (febrile vs afebrile, onset, frequency, type),
tics, staring spells, head trauma
Skin: rashes, petechiae, jaundice, infection, birthmarks
PHYSICAL EXAMINATION
General Inspection
- Sick vs not sick?
- Toxic appearance? listlessness, agitation, failure to recognize
parents, inadequate circulation (cool extremities; weak, rapid pulse;
poor capillary refill; cyanotic, gray, or mottled colour), respiratory
distress, purpura
- Level of consciousness
- Nutritional status well nourished?
- Developmental status (pulling up to stand in crib, running around
room)
- Dysmorphic features look specifically at face, ears, hands, feet,
genetalia
Vital Signs:
- Include Temperature, Heart Rate, Respiratory Rate, Blood Pressure
and O
2
saturation
NORMAL PEDIATRIC VITAL SIGNS
Age HR SBP RR
Newborn (<1 wk) 120-160 60-70 30-60
Neonate (<1 mos) 120-160 75-90 30-60
Infant (<1 year) 110-140 75-120 20-40
Preschool (3-5yrs) 90-120 75-125 20-25
Child (6-12 yrs) 80-110 83-120 16-24
Adolescent (>12 y) 70-100 90-130 12-18
Adult (>18 yrs) 60-100 90-130 12-18
MacPeds Survival Guide 14-15 37
Anthropometrics (plot on growth curves at every visit!):
- Height (supine length to 2 years, then standing height)
- Weight
- Head circumference (generally birth to 2 years, >2 yrs if specific
concerns)
- Plot BMI (kg/m
2
) on updated CDC growth curves for appropriate BMI
for age
- CDC Growth Curves available at:
http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_ch
arts.htm
Hydration Status
- Comment on mucous membranes, tears, skin turgor, sunken eyes, in
addition to appropriateness of vital signs, etc.
- For classification of mild, moderate, severe dehydration see Fluids
& Electrolytes
HEENT:
- Head: dysmorphic features, shape of skull, head circumference,
fontanels in infants
- Eyes: strabismus, pupillary response, fundoscopy, red reflex in
infants, conjunctivitis
- Ears & pharynx exam in any child with a fever!
- Nose: turbinates, deviation of septum, presence of polyps?
- Mouth: lips (lesions, colour), mucous membranes including gingiva,
tongue, hard/soft palate,
- Dentition: presence of teeth, tooth decay
- Neck: lymphadenopathy, palpation of thyroid, webbing (Noonan,
Turner syndrome), torticollis
MacPeds Survival Guide 14-15 38
Cardiovascular:
- HR, BP, apical beat, heaves/thrills
- Perfusion:
o Pulses strength/quality, femoral pulses in all infants
o Capillary refill time
o Skin colour: pink, central/peripheral cyanosis, mottling, pallor
- S1/S2, extra heart sounds (S3, S4)
- Murmurs:
o Timing (systole, diastole, continuous)
o Location of maximal intensity, radiation
o Pitch and quality (machinery, vibratory, etc),
o Loudness (I VI / VI)
Respiratory:
- Audible stridor, sturtor, wheeze, snoring
- Position of child, ability to handle secretions
- Signs of distress: nasal flaring, tracheal tug, indrawing
- RR, O
2
saturation (current FiO
2
), level of distress
- Able to speak in full sentences (if age appropriate)
- Depth and rhythm of respiration
-
- Chest wall deformities: kyphosis, scoliosis, pectus
excavatum/carinatum
- Finger clubbing
Abdomen:
- For peritoneal signs: ask child to jump up and down or wiggle hips, to
distend and retract abdomen blow up your belly and then suck it in
- Inspection: scaphoid/distended, umbilical hernias, diastasis recti
- Auscultation: presence of bowel sounds
- Percussion: ascites, liver span, Traubes space for splenomegaly
- Palpation: hepatosplenomegaly?, tenderness, guarding (voluntary,
involuntary), masses (particularly stool presence in LLQ)
- Stigmata of liver disease: jaundice, pruritis, bruising/bleeding, palmar
erythema, caput medusa, telangiectasia, ascites,
hepatosplenomegaly
MacPeds Survival Guide 14-15 39
Genito-urinary:
- Anal position, external inspection (digital rectal examination in kids
ONLY with clinical indication), Sexual Maturity Rating
- Male infants: both testes descended, hypospadias, inguinal hernias
- Females: labia majora/minora, vaginial discharge,
erythema/excoriation of vulvo-vaginitis (NO speculum exam if pre-
pubertal), Hymenal exam if indicated.
MSK:
- Gait assessment, flat feet vs toe walking vs normal foot arches
- Standing: genu valgum knock knee vs genu varum bow legged
- Joints: erythema, swelling, position, active/passive range of motion,
strength, muscle symmetry
- Back: kyphosis, scoliosis
http://www.youtube.com/watch?v=GQQBG9rlZp4
Neurological:
- Overall developmental assessment
o Try playing ball with younger children, or even peek-a-boo!
- Level of consciousness (Glasgow Coma Scale if appropriate)
- Newborns: primitive reflexes, moving all limbs, presence of fisting?
- Cranial nerves: by observation in infants, formal testing in older
children
- Motor: strength, tone, deep tendon reflexes, coordination
- Sensory: touch, temperature, position/vibration sense
- Cerebellar: gait (heel to toe, on heels, on toes, finger-to-nose, rapid
alternating movements in older children, Romberg (eyes open then
closed)
Derm:
- Jaundice, pallor, mottling, petechiae/purpura
- Rashes, birthmarks, hemangiomas, stigmata of neurocutaneous
disorders
MacPeds Survival Guide 14-15 40
Hands On
Medical Editor: Louise Warburton, GP. Production Editor: Frances Mawer (arc). ISSN 1741-833X.
Published 3 times a year by the Arthritis Research Campaign, Copeman House, St Marys Court, St Marys Gate
Chesterfield S41 7TD. Registered Charity No. 207711.
R E P O R T S O N T H E R H E U M A T I C D I S E A S E S S E R I E S 5
Practical advice on management of rheumatic disease
June 2008 No 15
Why do primary care doctors need
to know about musculoskeletal
assessment in children?
Children with musculoskeletal (MSK) problems are common
and often present initially to primary care where GPs
have an important role as gatekeepers to secondary care
and specialist services. The majority of causes of MSK
presentations in childhood are benign, self-limiting and
often trauma-related; referral is not always necessary, and
in many instances reassurance alone may sufce. However,
MSK symptoms can be presenting features of potentially life-
threatening conditions such as malignancy, sepsis, vasculitis
and non-accidental injury, and furthermore are commonly
associated features of many chronic paediatric conditions
such as inammatory bowel disease, cystic brosis, arthritis
and psoriasis. Clinical assessment skills (history-taking and
physical examination), knowledge of normal development,
and clinical presentations at different ages, along with
knowledge of indicators to warrant referral, are important
and facilitate appropriate decision-making in the primary
care setting. This article focuses on pGALS (paediatric Gait,
Arms, Legs, Spine), which is a simple screening approach
to MSK examination in school-aged children and may be
successfully performed in younger ambulant children
the approach to the examination of the toddler and baby
requires a different approach and is not described here.
How is musculoskeletal assessment
of children different to that of
adults?
It is stating the obvious that children are not small adults
in many ways, and here we focus on MSK history-taking
pGALS A SCREENING EXAMINATION OF THE MUSCULO-
SKELETAL SYSTEM IN SCHOOL-AGED CHILDREN
Helen E Foster, MD, MBBS(Hons), FRCP, FRCPCH, CertMedEd, Professor in Paediatric Rheumatology
Sharmila Jandial, MBChB, MRCPCH, CertMedEd, arc Educational Research Fellow
Musculoskeletal Research Group, Newcastle University, Newcastle upon Tyne
and physical examination. The history is often given by
the parent or carer, may be based on observations and
interpretation of events made by others (such as teachers),
and may be rather vague with non-specic complaints such
as My child is limping or My child is not walking quite
right. Young children may have difculty in localising or
describing pain in terms that adults may understand. It is not
unusual for young children to deny having pain when asked
directly, and instead present with changes in behaviour (e.g.
irritability or poor sleeping), decreasing ability or interest in
activities and hand skills (e.g. handwriting), or regression of
motor milestones. Some children are shy or frightened and
reluctant to engage in the consultation.
Practical Tip when inammatory joint disease is
suspected
The lack of reported pain does not exclude arthritis
There is a need to probe for symptoms such as
gelling (e.g. stiffness after long car rides)
altered function (e.g. play, handwriting skills,
regression of motor milestones)
deterioration in behaviour (irritability, poor
sleeping)
There is a need to examine all joints as joint involvement
is often asymptomatic
It is important to probe in the history when there are
indicators of potential inammatory MSK disease. A delay
in major motor milestones warrants MSK assessment as well
as a global neuro-developmental approach. However, in ac-
quired MSK disease such as juvenile idiopathic arthritis ( JIA)
a history of regression of achieved milestones is often more
signicant e.g. the child who was happy to walk unaided
but has recently been reluctant to walk or is now unable to
dress himself without help. In adults the cardinal features
of inammatory arthritis are pain, stiffness, swelling and
reduced function. However, in children these features may
MacPeds Survival Guide 14-15 41
be difcult to elucidate. Joint swelling, limping and reduced
mobility, rather than pain, are the most common presenting
features of JIA.
1
The lack of reported pain does not exclude
arthritis the child is undoubtedly in discomfort but, for the
reasons described, may not verbalise this as pain. Swelling is
always signicant but can be subtle and easily overlooked,
especially if the changes are symmetrical, and relies on
the examiner being condent in their MSK examination
skills and having an appreciation of what is normal and
abnormal (see below). Rather than describing stiffness, the
parents may notice the child is reluctant to weight-bear or
limps in the mornings or gels after periods of immobility
(e.g. after long car rides or sitting in a classroom). Systemic
upset and the presence of bone rather than joint pain may
be features of MSK disease and are red ags that warrant
urgent referral. More indolent presentations of MSK disease
can also impact on growth (either localised or generalised)
and it is important to assess height and weight and review
growth charts as necessary.
RED FLAGS
(Raise concern about infection, malignancy or non-
accidental injury)
Fever, malaise, systemic upset (reduced appetite,
weight loss, sweats)
Bone or joint pain with fever
Refractory or unremitting pain, persistent night-waking
Incongruence between history and presentation (such
as the pattern of the physical ndings and a previous
history of neglect)
What is pGALS?
Paediatric GALS (pGALS) is a simple evidence-based app-
roach to an MSK screening assessment in school-aged chil-
dren, and is based on the adult GALS (Gait, Arms, Legs,
Spine) screen.
2
The adult GALS screen is commonly taught
to medical students, and emerging evidence shows an
improvement in doctors condence and performance
in adult MSK assessment. Educational resources to
support learning of GALS are available.
3
pGALS is the only
paediatric MSK screening examination to be validated, and
was originally tested in school-aged children. pGALS has
been demonstrated to have excellent sensitivity to detect
abnormality (i.e. with few false negatives), incorporates
simple manoeuvres often used in clinical practice, and is
quick to do, taking an average of 2 minutes to perform.
4
Furthermore, when performed by medical students and
general practitioners pGALS has been shown to have high
sensitivity and is easy to do, with excellent acceptability by
children and their parents (papers in preparation). Younger
children can often perform the screening manoeuvres quite
easily, although validation of pGALS in the pre-school age
group has yet to be demonstrated.
When should pGALS be performed?
MSK presentations are a common feature of many chronic
diseases of childhood and not just arthritis. An MSK exam-
ination is one of the core systems along with cardiovascu-
2
lar, respiratory, gastrointestinal, neurological, skin and eyes,
and, given the broad spectrum of MSK presentations in chil-
dren, a low threshold for performing pGALS is suggested and
of particular importance in certain clinical scenarios.
Practical Tip when to perform pGALS in the
assessment
Child with muscle, joint or bone pain
Unwell child with pyrexia
Child with limp
Delay or regression of motor milestones
The clumsy child in the absence of neurological
disease
Child with chronic disease and known association with
MSK presentations
How does pGALS differ from adult
GALS?
The sequence of pGALS is essentially the same as adult GALS
with additional manoeuvres to screen the foot and ankle
(walk on heels and then on tiptoes), wrists (palms together
and then hands back to back) and temporomandibular joints
(open mouth and insert three of the childs own ngers),
and with amendments at screening the elbow (reach up
and touch the sky) and neck (look at the ceiling). These ad-
ditional manoeuvres were included because when adult
GALS was originally tested in school-aged children
4
it missed
signicant abnormalities at these sites.
How to distinguish normal from
abnormal in the musculoskeletal
examination
Key to distinguishing normal from abnormal are knowledge
of ranges of movement, looking for asymmetry and
careful examination for subtle changes. In addition, it is
important that GPs are aware of normal variants in gait,
leg alignment and normal motor milestones (Tables 1,2) as
these are a common cause of parental concern, especially
in the pre-school child, and often anxieties can be allayed
with explanation and reassurance. There is considerable
variation in the way normal gait patterns develop; these
may be familial (e.g. bottom-shufers often walk later) and
subject to racial variation (e.g. African black children tend to
walk sooner and Asian children later than average).
Joint abnormalities can be subtle or difcult to appreciate
in the young (such as chubby ankles, ngers, wrists and
knees). Looking for asymmetrical changes is helpful
although it can be falsely reassuring in the presence of
symmetrical joint involvement. Muscle wasting, such as
of the quadriceps or calf muscles, indicates chronicity of
joint disease and should alert the examiner to knee or
ankle involvement respectively. Swelling of the ankle is
often best judged from behind the child. Ranges of joint
movement should be symmetrical and an appreciation of
the normal range of movement in childhood can be gained
with increased clinical experience. Hypermobility may be
generalised or limited to peripheral joints such as hands
MacPeds Survival Guide 14-15 42
3
and feet, and, generally speaking, younger female children
and those of non-Caucasian origin are more exible. Benign
hypermobility is suggested by symmetrical hyperextension
at the ngers, elbows and knees and by at pronated feet,
with normal arches on tiptoe.
5
Practical Tip normal variants: indications for referral
Persistent changes (beyond the expected age ranges)
Progressive or asymmetrical changes
Short stature or dysmorphic features
Painful changes with functional limitation
Regression or delayed motor milestones
Abnormal joint examination elsewhere
Suggestion of neurological disease or developmental
delay
Children with hypermobility may present with mechanical
aches and pains after activity or as clumsy children, prone
to falls. It is important to consider non-benign causes of
hypermobility such as Marfans syndrome (which may be
suggested by tall habitus with long thin ngers, and high-
arched palate), and EhlersDanlos syndrome (which may
be suggested by easy bruising and skin elasticity, with poor
healing after minor trauma). Non-benign hypermobility is
genetically acquired and probing into the family history may
be revealing (e.g. cardiac deaths in Marfans syndrome).
The absence of normal arches on tiptoe suggests a non-
mobile at foot and warrants investigation (e.g. to exclude
tarsal coalition) and high xed arches and persistent toe-
walking may suggest neurological disease. Conversely,
lack of joint mobility, especially if asymmetrical, is always
signicant. Increased symmetrical calf muscle bulk as-
sociates with types of muscular dystrophy, and proximal my-
opathies may be suggested by delayed milestones such as
walking (later than 18 months) or inability to jump (in the
school-aged child).
What to do if the pGALS screen is
abnormal
pGALS has been shown to have high sensitivity to detect
signicant abnormalities. Following the screening exam-
ination, the observer is directed to a more detailed examin-
ation of the relevant area, based on the look, feel, move
principle as in the adult Regional Examination of the
Musculoskeletal System (called REMS).
3
To date a validated
regional MSK examination for children does not exist, but
an evidence- and consensus-based approach to a childrens
regional examination (to be called pREMS) is currently being
developed by our research team; this project is funded by
arc and further educational resources are to follow.
The components of the pGALS mus-
culoskeletal screen
The pGALS screen
6
(see pp 46) includes three questions
relating to pain and function. However, a negative response
to these three questions in the context of a potential MSK
problem does not exclude signicant MSK disease, and
TABLE 1. Normal variants in gait patterns and leg
alignment.
Toe-
walking
Habitual toe-walking is common in
young children up to 3 years
In-toeing Can be due to:
persistent femoral anteversion
(characterised by child walking with
patellae and feet pointing inwards;
common between ages 38 years)
internal tibial torsion (characterised
by child walking with patellae facing
forward and toes pointing inwards;
common from onset of walking to
3 years)
metatarsus adductus (characterised
by a exible C-shaped lateral border
of the foot; most resolve by 6 years
Bow legs
(genu
varus)
Common from birth to the early toddler,
often with out-toeing (maximal at approx.
1 year); most resolve by 18 months
Knock
knees
(genu
valgus)
Common and often associated with
in-toeing (maximal at approx. 4 years);
most resolve by 7 years
Flat feet Most children have exible at feet with
normal arches on tiptoeing; most resolve
by 6 years
Crooked
toes
Most resolve with weight-bearing
(assuming shoes and socks t
comfortably)
TABLE 2. Normal major motor milestones.
Sit without support 68 months
Creep on hands and knees 911 months
Cruise when holding on to
furniture and standing upright,
or bottom shufe
1112 months
Walk independently 1214 months
Climb up stairs on hands and
knees
approx. 15 months
Run stify approx. 16 months
Walk down steps (non-reciprocal) 2024 months
Walk up steps, alternate feet 3 years
Hop on one foot, broad jump 4 years
Skip with alternate feet 5 years
Balance on one foot 20 seconds 67 years
MacPeds Survival Guide 14-15 43
4
The pGALS musculoskeletal screen
Screening questions
Do you (or does your child) have any pain or stiffness in your (their) joints, muscles or back?
Do you (or does your child) have any diffculty getting yourself (him/herself) dressed without any help?
Do you (or does your child) have any problem going up and down stairs?
FIGURE SCREENING MANOEUVRES
(Note the manoeuvres in bold are
additional to those in adult GALS
2
)
WHAT IS BEING ASSESSED?
Observe the child standing
(from front, back and sides)
Posture and habitus
Skin rashes e.g. psoriasis
Deformity e.g. leg length
inequality, leg alignment
(valgus, varus at the knee
or ankle), scoliosis, joint
swelling, muscle wasting,
at feet
Observe the child walking
and
Walk on your heels and
Walk on your tiptoes
Ankles, subtalar, midtarsal
and small joints of feet
and toes
Foot posture (note if
presence of normal
longitudinal arches of feet
when on tiptoes)
Hold your hands out
straight in front of you
Forward exion of
shoulders
Elbow extension
Wrist extension
Extension of small joints
of ngers
Turn your hands over and
make a st
Wrist supination
Elbow supination
Flexion of small joints of
ngers
Pinch your index nger and
thumb together
Manual dexterity
Coordination of small
joints of index nger and
thumb and functional
key grip
(continued)
MacPeds Survival Guide 14-15 44
5
(continued)
FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?
Touch the tips of your
ngers
Manual dexterity
Coordination of small
joints of ngers and
thumbs
Squeeze the metacarpo-
phalangeal joints for
tenderness
Metacarpophalangeal
joints
Put your hands together
palm to palm and
Put your hands together
back to back
Extension of small joints
of ngers
Wrist extension
Elbow exion
Reach up, touch the sky
and
Look at the ceiling
Elbow extension
Wrist extension
Shoulder abduction
Neck extension
Put your hands behind your
neck
Shoulder abduction
External rotation of
shoulders
Elbow exion
MacPeds Survival Guide 14-15 45
6
FIGURE SCREENING MANOEUVRES WHAT IS BEING ASSESSED?
Try and touch your shoulder
with your ear
Cervical spine lateral
exion
Open wide and put three
(childs own) ngers in your
mouth
Temporomandibular joints
(and check for deviation of
jaw movement)
Feel for effusion at the
knee (patella tap, or cross-
uctuation)
Knee effusion (small
effusion may be missed
by patella tap alone)
Active movement of knees
(exion and extension) and
feel for crepitus
Knee exion
Knee extension
Passive movement of hip
(knee exed to 90, and
internal rotation of hip)
Hip exion and internal
rotation
Bend forwards and touch
your toes?
Forward exion of
thoraco-lumbar spine (and
check for scoliosis)
MacPeds Survival Guide 14-15 46
7
therefore at a minimum pGALS should be performed. In
children, it is not uncommon to nd joint involvement
that has not been mentioned as part of the presenting
complaint; it is therefore essential to perform all parts of
the pGALS screen and check for verbal and non-verbal clues
of joint discomfort (such as facial expression, withdrawal of
limb, or refusal to be examined further).
Observation with the child standing should be done from the
front, behind the child and from the side. Scoliosis may be
suggested by unequal shoulder height or asymmetrical skin
creases on the trunk, and may be more obvious on forward
exion. From the front and back, leg alignment problems
such as valgus and varus deformities at the knee can be
observed; leg-length inequality may be more obvious from
the side and suggested by a exed posture at the knee, and,
if found, then careful observation of the spine is important
to exclude a secondary scoliosis. For specic manoeuvres,
the child can copy the various screening manoeuvres as
they are performed by the examiner. Children often nd
this fun and this can help with establishing rapport. It is
important to keep observing closely as children may only
cooperate briey! The examination of the upper limbs and
neck is optimal with the child sitting on an examination
couch or on a parents knee, facing the examiner. The child
should then lie supine to allow the legs to be examined and
then stand again for spine assessment.
Practical Tip while performing the pGALS screening
examination
Get the child to copy you doing the manoeuvres
Look for verbal and non-verbal clues of discomfort
(e.g. facial expression, withdrawal)
Do the full screen as the extent of joint involvement may
not be obvious from the history
Look for asymmetry (e.g. muscle bulk, joint swelling,
range of joint movement)
Consider clinical patterns (e.g. non-benign hypermobility
and Marfanoid habitus or skin elasticity) and association
of leg-length discrepancy and scoliosis)
pGALS screening questions
Any pain? Left knee
Problems with dressing? No difficulty
Problems with walking? Some difficulty on walking
Appearance Movement
Gait 7
Arms 3 3
Legs 7 7
Spine 3 3
Documentation of the pGALS screen
Documentation of the pGALS screening assessment is important and a simple pro forma is proposed with
the following example a child with a swollen left knee with limited exion of the knee and antalgic gait.
Summary
The pGALS examination is a simple MSK screen that should
be performed as part of systems assessment of children.
Improved performance of MSK clinical skills and knowledge
of normal variants in childhood, common MSK conditions
and their mode of presentation, along with knowledge
of red ags to warrant concern, will facilitate diagnosis,
management and appropriate referral.
Further information and reading
A full demonstration of the pGALS screen is available from the Arthritis
Research Campaign (arc) as a free resource as a DVD and soon will
be available as a web-based resource: www.arc.org.uk/arthinfo/
emedia.asp. A video-clip of the screening manoeuvres can also be
accessed via the web version of this report: www.arc.org.uk/arthinfo/
medpubs/6535/6535.asp.
Jandial S, Foster HE. Examination of the musculoskeletal system in chil-
dren: a simple approach. Paediatr Child Health 2008;18(2):47-55.
Szer I, Kimura Y, Malleson P, Southwood T (ed). Arthritis in adolescents
and children ( juvenile idiopathic arthritis). Oxford University Press;
2006.
References
1. McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying children with
chronic arthritis based on chief complaints: absence of predictive
value for musculoskeletal pain as an indicator of rheumatic disease
in children. Pediatrics 2002;110(2 Pt 1):354-9.
2. Doherty M, Dacre J, Dieppe P, Snaith M. The GALS locomotor
screen. Ann Rheum Dis 1992;51(10):1165-9.
3. Clinical assessment of the musculoskeletal system: a handbook
for medical students (includes DVD Regional examination of the
musculoskeletal system for students). Arthritis Research Campaign;
2005. www.arc.org.uk/arthinfo/medpubs/6321/6321.asp.
4. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal
screening examination (pGALS) for school-aged children based on
the adult GALS screen. Arthritis Rheum 2006;55(5):709-16.
5. Oliver J. Hypermobility. Reports on the Rheumatic Diseases (Series
5), Hands On 7. Arthritis Research Campaign; 2005 Oct.
6. pGALS Paediatric Gait, Arms, Legs, Spine. DVD. Arthritis Research
Campaign; 2006. www.arc.org.uk/arthinfo/emedia.asp.
MacPeds Survival Guide 14-15 47
BOYS
L
E
N
G
T
H
L
E
N
G
T
H
W
E
I
G
H
T
W
E
I
G
H
T
Birth 2 8 6 4 12 14 16 18 20 22 24 10
Birth 2 6 8 4
12 14 16 18 20 22 24 10
6
4
kg
7
75
85
90
95
80 80
16
14
12
20
25
30
35
40
45
50
55
60
70
75
65
90
95
10
9
8
7
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
in
29
30
31
32
33
34
35
36
37
38
39
in
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BIRTH TO 24 MONTHS: BOYS
Length-for-age and Weight-for-age percentiles
WHO GROWTH CHARTS FOR CANADA
NAME:
DOB: RECORD #
85
10
12
14
8
2
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
20
22
24
26
28
30
32
34
36
38
AGE (MONTHS)
AGE (MONTHS)
kg
lb
lb
kg
lb
cm cm
BOYS
MOTHERS HEIGHT
FATHERS HEIGHT WEEKS
DATE AGE
BIRTH
LENGTH WEIGHT COMMENTS
GESTATIONAL AGE AT BIRTH
3
15
50
85
97
3
15
50
85
97
MacPeds Survival Guide 14-15 48
BOYS
in
cm
18 19 20 21 22 23 24 25 26
60 58 56 54 52 50 48 46 62 64 66
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Birth 2 8 6 4 12 14 16 18 20 22 24 10
7
kg
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
44
46
50
52
54
48
20 30
13
12
14
15
16
17
18
19
20
21
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BIRTH TO 24 MONTHS: BOYS
Head Circumference and Weight-for-length percentiles
WHO GROWTH CHARTS FOR CANADA
NAME:
DOB: RECORD #
AGE (MONTHS)
LENGTH
W
E
I
G
H
T
W
E
I
G
H
T
in
17
18
19
20
21
in
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
E
BOYS
cm cm
32
48
36
38
40
42
44
46
52
54
50
34
22
24
26
28
30
32
34
36
38
20
18
16
14
12
10
8
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
52
54
20
18
16
14
12
lb
8
6
lb
kg
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
82 80 78 88 86 84 94 92 90 100 98 96 106 108 104 102 76 74 72 70
in
cm
DATE AGE
BIRTH
LENGTH WEIGHT HEAD CIRC. COMMENTS
WEEKS GESTATIONAL AGE AT BIRTH
97
85
50
15
3
99.9
97
85
50
15
3
MacPeds Survival Guide 14-15 49
BOYS
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
26
24
22
20
18
16
14
12
28
26
24
22
20
18
16
14
12
30
32
34
13
15
17
19
21
23
25
27
28
29
30
31
34
35
36
37
38
39
13
15
17
19
21
23
25
27
29
31
33
35
36
37
38
39
AGE (YEARS)
2 TO 19 YEARS: BOYS
Body mass index-for-age percentiles
WHO GROWTH CHARTS FOR CANADA
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BMI
BMI
BMI
BMI
NAME:
DOB: RECORD #
BOYS
BMI
DATE AGE WEIGHT HEIGHT BMI* COMMENTS
BMI tables/calculator available at www.whogrowthcharts.ca
*To Calculate BMI: Weight (kg) Height (cm) Height (cm) x 10,000 OR
Weight (lb) Height (in) Height (in) x 703
97
85
50
15
3
99.9
MacPeds Survival Guide 14-15 50
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
HEIGHT
(CM)
BODY WEIGHT
(KILOGRAMS)
HEIGHT
(CM)
75 6.2 6.8 7.3 7.9 8.4 9.0 9.6 10.1 10.7 11.3 11.8 12.4 12.9 13.5 14.1 14.6 15 16 16 17 17 18 19 19 20 20 21 21 22 75
80 7.0 7.7 8.3 9.0 9.6 10.2 10.9 11.5 12.2 12.8 13.4 14.1 14.7 15 16 17 17 18 19 19 20 20 21 22 22 23 24 24 25 80
85 7.9 8.7 9.4 10.1 10.8 11.6 12.3 13.0 13.7 14.5 15 16 17 17 18 19 20 20 21 22 22 23 24 25 25 26 27 27 28 85
90 8.9 9.7 10.5 11.3 12.2 13.0 13.8 14.6 15 16 17 18 19 19 20 21 22 23 23 24 25 26 27 28 28 29 30 31 32 90
95 9.9 10.8 11.7 12.6 13.5 14.4 15 16 17 18 19 20 21 22 23 23 24 25 26 27 28 29 30 31 32 32 33 34 35 95
100 11.0 12.0 13.0 14.0 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 100
105 12.1 13.2 14.3 15 17 18 19 20 21 22 23 24 25 26 28 29 30 31 32 33 34 35 36 37 39 40 41 42 43 105
110 13.3 14.5 16 17 18 19 21 22 23 24 25 27 28 29 30 31 33 34 35 36 38 39 40 41 42 44 45 46 47 110
115 14.5 16 17 19 20 21 22 24 25 26 28 29 30 32 33 34 36 37 38 40 41 42 44 45 46 48 49 50 52 115
120 16 17 19 20 22 23 24 26 27 29 30 32 33 35 36 37 39 40 42 43 45 46 48 49 50 52 53 55 56 120
125 17 19 20 22 23 25 27 28 30 31 33 34 36 38 39 41 42 44 45 47 48 50 52 53 55 56 58 59 61 125
130 19 20 22 24 25 27 29 30 32 34 35 37 39 41 42 44 46 47 49 51 52 54 56 57 59 61 63 64 66 130
135 20 22 24 26 27 29 31 33 35 36 38 40 42 44 46 47 49 51 53 55 56 58 60 62 64 66 67 69 71 135
140 22 24 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 74 76 140
145 23 25 27 29 32 34 36 38 40 42 44 46 48 50 53 55 57 59 61 63 65 67 69 71 74 76 78 80 82 145
150 25 27 29 32 34 36 38 41 43 45 47 50 52 54 56 59 61 63 65 68 70 72 74 77 79 81 83 86 88 150
155 26 29 31 34 36 38 41 43 46 48 50 53 55 58 60 62 65 67 70 72 74 77 79 82 84 86 89 91 94 155
160 28 31 33 36 38 41 44 46 49 51 54 56 59 61 64 67 69 72 74 77 79 82 84 87 90 92 95 97 100 160
165 30 33 35 38 41 44 46 49 52 54 57 60 63 65 68 71 74 76 79 82 84 87 90 93 95 98 101 103 106 165
170 32 35 38 40 43 46 49 52 55 58 61 64 66 69 72 75 78 81 84 87 90 92 95 98 101 104 107 110 113 170
175 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 86 89 92 95 98 101 104 107 110 113 116 119 175
180 36 39 42 45 49 52 55 58 62 65 68 71 75 78 81 84 87 91 94 97 100 104 107 110 113 117 120 123 126 180
185 38 41 44 48 51 55 58 62 65 68 72 75 79 82 86 89 92 96 99 103 106 110 113 116 120 123 127 130 133 185
190 40 43 47 51 54 58 61 65 69 72 76 79 83 87 90 94 97 101 105 108 112 116 119 123 126 130 134 137 141 190
195 42 46 49 53 57 61 65 68 72 76 80 84 87 91 95 99 103 106 110 114 118 122 125 129 133 137 141 144 148 195
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
BODY MASS INDEX TABLE TO CALCULATE FROM CENTIMETRES AND KILOGRAMS
USE TO CALCULATE BMI FOR THOSE AGED 2 YEARS OF AGE OR MORE
For greater precision or to calculate BMI values greater than 39, use the following equation: Weight (kg) Height (cm) Height (cm) x 10,000
Dietitians of Canada, 2010. May be reproduced in its entirety (i.e., no changes) for educational purposes only.
MacPeds Survival Guide 14-15 51
BOYS
3 2 6 5 4 8 9 10 11 12 13 14 15 16 17 18 19 7
3 2 6 5 4 8 9 10 11 12 13 14 15 16 17 18 19 7
20
30
40
50
200 200
195
190
185
180
175
170
165
160
155
150
145
195
190
185
175
180
170
165
160
155
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
SOURCE: The main chart is based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group (CPEG), College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada. The weight-for-age10 to 19 years
section was developed by CPEG based on data from the US National Center for Health Statisticsusing the same procedures as the WHO growth charts.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
2 TO 19 YEARS: BOYS
Height-for-age and Weight-for-age percentiles
WHO GROWTH CHARTS FOR CANADA
NAME:
DOB: RECORD #
10
15
20
25
10
15
20
25
30
40
45
50
55
60
65
70
75
80
85
90
AGE (YEARS)
W
E
I
G
H
T
H
E
I
G
H
T
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
71
70
72
73
74
75
76
77
78
79
80
38
37
36
35
34
33
32
31
in
68
69
70
71
72
73
62
63
64
65
66
67
56
57
58
59
60
61
74
75
76
77
78
79
80
in
20
30
40
50
60
80
90
100
lb
110
120
130
140
150
160
170
180
190
200
kg lb kg
70
cm cm
35
BOYS
W
E
I
G
H
T
H
E
I
G
H
T
AGE (YEARS)
WHO recommends BMI as the best measure
after age 10 due to variable age of puberty.
Tracking weight alone is not advised.
MOTHERS HEIGHT
FATHERS HEIGHT
DATE AGE HEIGHT WEIGHT COMMENTS
3
15
50
85
97
3
15
50
85
97
MacPeds Survival Guide 14-15 52
GIRLS
L
E
N
G
T
H
L
E
N
G
T
H
W
E
I
G
H
T
W
E
I
G
H
T
Birth 2 8 6 4 12 14 16 18 20 22 24 10
Birth 2 6 8 4
12 14 16 18 20 22 24 10
6
4
kg
7
75
85
90
95
80 80
16
14
12
20
25
30
35
40
45
50
55
60
70
75
65
90
95
10
9
8
7
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
in
29
30
31
32
33
34
35
36
37
38
39
in
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BIRTH TO 24 MONTHS: GIRLS
Length-for-age and Weight-for-age percentiles
WHO GROWTH CHARTS FOR CANADA
NAME:
DOB: RECORD #
85
10
12
14
8
2
3
4
5
6
8
9
10
11
12
13
14
15
16
17
18
20
22
24
26
28
30
32
34
36
38
AGE (MONTHS)
AGE (MONTHS)
kg
lb
lb
kg
lb
cm cm
GIRLS
MOTHERS HEIGHT
FATHERS HEIGHT WEEKS
DATE AGE
BIRTH
LENGTH WEIGHT COMMENTS
GESTATIONAL AGE AT BIRTH
3
15
50
85
97
3
15
50
85
97
MacPeds Survival Guide 14-15 53
GIRLS
in
cm
18 19 20 21 22 23 24 25 26
60 58 56 54 52 50 48 46 62 64 66
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
7
kg
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LENGTH
W
E
I
G
H
T
W
E
I
G
H
T
22
24
26
28
30
32
34
36
38
40
20
18
16
14
12
10
8
22
24
26
28
30
32
34
36
38
40
42
44
46
48
50
52
54
20
18
16
14
12
lb
6
lb
kg
Birth 2 8 6 4 12 14 16 18 20 22 24 10
42
44
48
50
52
46
20 28
13
12
11
14
15
16
17
18
19
20
AGE (MONTHS)
in
18
17
19
20
in
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
E
cm cm
30
46
34
36
38
40
42
44
50
52
48
32
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BIRTH TO 24 MONTHS: GIRLS
Head Circumference and Weight-for-length percentiles
WHO GROWTH CHARTS FOR CANADA
NAME:
DOB: RECORD #
GIRLS
27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
82 80 78 88 86 84 94 92 90 100 98 96 106 108 104 102 76 74 72 70
in
cm
DATE AGE
BIRTH
LENGTH WEIGHT HEAD CIRC. COMMENTS
WEEKS GESTATIONAL AGE AT BIRTH
97
85
50
15
3
99.9
97
85
50
15
3
MacPeds Survival Guide 14-15 54
GIRLS
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
27
25
23
21
19
17
15
13
29
27
25
23
21
19
17
15
13
31
33
35
14
16
18
20
22
24
26
28
29
30
31
32
35
36
37
38
39
14
16
18
20
22
24
26
28
30
32
34
36
37
38
39
40
AGE (YEARS)
2 TO 19 YEARS: GIRLS
Body mass index-for-age percentiles
WHO GROWTH CHARTS FOR CANADA
SOURCE: Based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) and adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group, College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
BMI
BMI 33
BMI
BMI
BMI
NAME:
DOB: RECORD #
GIRLS
BMI
DATE AGE WEIGHT HEIGHT BMI* COMMENTS
BMI tables/calculator available at www.whogrowthcharts.ca
*To Calculate BMI: Weight (kg) Height (cm) Height (cm) x 10,000 OR
Weight (lb) Height (in) Height (in) x 703
97
85
50
15
3
99.9
MacPeds Survival Guide 14-15 55
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
HEIGHT
(CM)
BODY WEIGHT
(KILOGRAMS)
HEIGHT
(CM)
75 6.2 6.8 7.3 7.9 8.4 9.0 9.6 10.1 10.7 11.3 11.8 12.4 12.9 13.5 14.1 14.6 15 16 16 17 17 18 19 19 20 20 21 21 22 75
80 7.0 7.7 8.3 9.0 9.6 10.2 10.9 11.5 12.2 12.8 13.4 14.1 14.7 15 16 17 17 18 19 19 20 20 21 22 22 23 24 24 25 80
85 7.9 8.7 9.4 10.1 10.8 11.6 12.3 13.0 13.7 14.5 15 16 17 17 18 19 20 20 21 22 22 23 24 25 25 26 27 27 28 85
90 8.9 9.7 10.5 11.3 12.2 13.0 13.8 14.6 15 16 17 18 19 19 20 21 22 23 23 24 25 26 27 28 28 29 30 31 32 90
95 9.9 10.8 11.7 12.6 13.5 14.4 15 16 17 18 19 20 21 22 23 23 24 25 26 27 28 29 30 31 32 32 33 34 35 95
100 11.0 12.0 13.0 14.0 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 100
105 12.1 13.2 14.3 15 17 18 19 20 21 22 23 24 25 26 28 29 30 31 32 33 34 35 36 37 39 40 41 42 43 105
110 13.3 14.5 16 17 18 19 21 22 23 24 25 27 28 29 30 31 33 34 35 36 38 39 40 41 42 44 45 46 47 110
115 14.5 16 17 19 20 21 22 24 25 26 28 29 30 32 33 34 36 37 38 40 41 42 44 45 46 48 49 50 52 115
120 16 17 19 20 22 23 24 26 27 29 30 32 33 35 36 37 39 40 42 43 45 46 48 49 50 52 53 55 56 120
125 17 19 20 22 23 25 27 28 30 31 33 34 36 38 39 41 42 44 45 47 48 50 52 53 55 56 58 59 61 125
130 19 20 22 24 25 27 29 30 32 34 35 37 39 41 42 44 46 47 49 51 52 54 56 57 59 61 63 64 66 130
135 20 22 24 26 27 29 31 33 35 36 38 40 42 44 46 47 49 51 53 55 56 58 60 62 64 66 67 69 71 135
140 22 24 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 74 76 140
145 23 25 27 29 32 34 36 38 40 42 44 46 48 50 53 55 57 59 61 63 65 67 69 71 74 76 78 80 82 145
150 25 27 29 32 34 36 38 41 43 45 47 50 52 54 56 59 61 63 65 68 70 72 74 77 79 81 83 86 88 150
155 26 29 31 34 36 38 41 43 46 48 50 53 55 58 60 62 65 67 70 72 74 77 79 82 84 86 89 91 94 155
160 28 31 33 36 38 41 44 46 49 51 54 56 59 61 64 67 69 72 74 77 79 82 84 87 90 92 95 97 100 160
165 30 33 35 38 41 44 46 49 52 54 57 60 63 65 68 71 74 76 79 82 84 87 90 93 95 98 101 103 106 165
170 32 35 38 40 43 46 49 52 55 58 61 64 66 69 72 75 78 81 84 87 90 92 95 98 101 104 107 110 113 170
175 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 86 89 92 95 98 101 104 107 110 113 116 119 175
180 36 39 42 45 49 52 55 58 62 65 68 71 75 78 81 84 87 91 94 97 100 104 107 110 113 117 120 123 126 180
185 38 41 44 48 51 55 58 62 65 68 72 75 79 82 86 89 92 96 99 103 106 110 113 116 120 123 127 130 133 185
190 40 43 47 51 54 58 61 65 69 72 76 79 83 87 90 94 97 101 105 108 112 116 119 123 126 130 134 137 141 190
195 42 46 49 53 57 61 65 68 72 76 80 84 87 91 95 99 103 106 110 114 118 122 125 129 133 137 141 144 148 195
BMI: 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
BODY MASS INDEX TABLE TO CALCULATE FROM CENTIMETRES AND KILOGRAMS
USE TO CALCULATE BMI FOR THOSE AGED 2 YEARS OF AGE OR MORE
For greater precision or to calculate BMI values greater than 39, use the following equation: Weight (kg) Height (cm) Height (cm) x 10,000
Dietitians of Canada, 2010. May be reproduced in its entirety (i.e., no changes) for educational purposes only.
MacPeds Survival Guide 14-15 56
GIRLS
3 2 6 5 4 8 9 10 11
12 13 14 15 16 17 18 19
7
3 2 6 5 4 8 9 10 11 12 13 14 15 16 17 18 19 7
20
30
40
50
195 195
190
185
180
175
170
165
160
155
150
145
140
190
185
180
170
175
165
160
155
150
145
140
135
130
125
120
115
110
105
100
95
90
85
80
75
SOURCE: The main chart is based on World Health Organization (WHO) Child Growth Standards (2006) and WHO Reference (2007) adapted for Canada by Canadian Paediatric Society,
Canadian Pediatric Endocrine Group (CPEG), College of Family Physicians of Canada, Community Health Nurses of Canada andDietitians of Canada. The weight-for-age10 to 19 years
section was developed by CPEG based on data from the US National Center for Health Statisticsusing the same procedures as the WHO growth charts.
Dietitians of Canada, 2014. Chart may be reproduced in its entirety (i.e., no changes) for non-commercial purposes only. www.whogrowthcharts.ca
2 TO 19 YEARS: GIRLS
Height-for-age and Weight-for-age percentiles
WHO GROWTH CHARTS FOR CANADA GIRLS
NAME:
DOB: RECORD #
10
15
20
25
10
15
20
25
30
40
45
50
55
60
65
70
75
80
85
90
AGE (YEARS)
AGE (YEARS)
W
E
I
G
H
T
H
E
I
G
H
T
W
E
I
G
H
T
H
E
I
G
H
T
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
71
70
72
73
74
75
76
77
78
38
37
36
35
34
33
32
31
30
29
in
68
69
70
71
72
73
62
63
64
65
66
67
56
55
54
57
58
59
60
61
74
75
76
77
78
in
20
30
40
50
60
80
90
100
lb
110
120
130
140
150
160
170
180
190
200
kg lb kg
lb
cm cm
35
MOTHERS HEIGHT
FATHERS HEIGHT
DATE AGE HEIGHT WEIGHT COMMENTS
3
15
50
85
97
3
15
50
85
97
WHO recommends BMI as the best measure
after age 10 due to variable age of puberty.
Tracking weight alone is not advised.
MacPeds Survival Guide 14-15 57
WEIGHT CONVERSION CHART
OUNCES
P
O
U
N
D
S
0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
0 0 28 57 85 113 142 170 198 227 255 284 312 340 369 397 425
1 454 482 510 539 567 595 624 652 680 709 737 765 794 822 851 879
2 907 936 964 992 1021 1049 1077 1106 1134 1162 1191 1219 1247 1276 1304 1332
3 1361 1399 1418 1446 1474 1503 1531 1559 1588 1616 1644 1673 1701 1729 1758 1786
4 1814 1843 1871 1899 1928 1956 1985 2013 2041 2070 2098 2126 2155 2183 2211 2240
5 2268 2296 2325 2353 2381 2410 2438 2466 2495 2523 2552 2580 2608 2637 2665 2693
6 2722 2750 2778 2807 2835 2863 2892 2920 2948 2977 3005 3033 3062 3090 3119 3147
7 3175 3204 3232 3260 3289 3317 3345 3374 3402 3430 3459 3487 3515 3544 3572 3600
8 3629 3657 3686 3714 3742 3771 3799 3827 3856 3884 3912 3941 3969 3997 4026 4054
9 4082 4111 4139 4167 4196 4224 4252 4281 4309 4338 4366 4394 4423 4451 4479 4508
10 4536 4564 4593 4621 4649 4678 4706 4734 4763 4791 4820 4848 4876 4905 4933 4961
11 4990 5018 5046 5075 5103 5131 5160 5188 5216 5245 5273 5301 5330 5358 5387 5415
12 5443 5472 5500 5528 5557 5585 5613 5642 5670 5698 5727 5755 5783 5812 5840 5868
13 5897 5925 5954 5982 6010 6039 6067 6095 6124 6152 6180 6209 6237 6265 6294 6322
14 6350 6379 6407 6435 6464 6492 6521 6549 6577 6606 6634 6662 6691 6719 6747 6776
15 6804 6832 6861 6889 6917 6946 6974 7002 7031 7059 7088 7116 7144 7173 7201 7229
MacPeds Survival Guide 14-15 58
ADOLESCENT INTERVIEWING (HEADDSS)
Interview teens alone with parents invited to join at the end
(Alternatively, you can start with the parents in the room and
have them leave at some point)
Allow adequate, uninterrupted time to inquire about all
aspects of their life, and high-risk behaviours in private
setting
Assure confidentiality at beginning of interview, and prior to
discussing drug use and sexuality
In addition to HEADDSS obtain routine history including:
Past Medical History, Meds, Allergies and Vaccines (HPV,
hepatitis, meningococcal in particular)
Home
Tell me what home is like!
Who lives at home? How does everyone get along? What do
you argue about? What are the rules like at home?
Any new people living at home?
Family members ages, occupations/education, health
status, substance abuse
Education / Employment
Name of school, grade level, attendance pattern
Most favourite/least favourite courses, marks in each course,
change in marks recently?
Part-time / full-time job for $ or experience
What are your educational goals? What are your
employment goals?
Activities
What do you do for fun? On weekends?
Do you feel you have enough friends? Who are your best
friends? What do you do together?
Sports / Exercise, extra-curricular activities
MacPeds Survival Guide 14-15 59
ADOLESCENT INTERVIEWING (Continued)
Drugs
Have you ever tried cigarettes? Alcohol? Marijuana?
Ever drunk?
Binge drinking on weekends?
For younger teens: ask about friends use and peer pressure
Cover all drug classes: hallucinogens, amphetamines, rave
drugs, IV drugs, crack cocaine, OTC meds, anabolic steroids
What age did you start? Frequency of use? How much?
What do you like/dislike about X? Why do you use X ?
Do you use alone? Any police involvement? Dealing?
Dieting
Do you have concerns about your weight/shape?
Have you tried to change your weight/shape in any way?
(dieting/exercise)
Presence of bingeing/purging behaviours, use of
diuretics/laxatives
Tell me what you eat/drink in an average day!
~20% of teens are on a diet at any one time, up to 66% have
tried to lose weight in the past
Use BMI curves to estimate healthy weight for teen based
on height
Sexuality
Over 2/3 of teens have had one sexual partner by age 18
The average age of first intercourse in Canada is 16 years
For female adolescents:
How old were you when you started your periods?
How often do you have your period? How may days does it
last for?
Are your periods heavy or painful?
How often do you miss school because of your period?
For all adolescents:
MacPeds Survival Guide 14-15 60
ADOLESCENT INTERVIEWING (Continued)
Are you interested in the same sex, opposite sex or both?
(DO NOT assume heterosexuality!)
Are you dating someone now? Are you having sex? What
kinds of sex (oral/anal/vaginal)? What do you use for
contraception/STI prevention (condoms, OCP, Depo-
provera, Emergency Contraception etc.)
Have you ever been forced or pressured into having sex?
Number of sexual partners /age of first sexual activity/STI
history / ever tested for STIs, HIV/ last pelvic exam in
females, partner history of STI and partners STI risk
behaviours
Have you ever been pregnant or gotten someone pregnant?
Suicide / Depression
Screen for depression (SIGECAPS)
Have you lost interest in things you previously enjoyed?
How would you describe your mood? On a scale of 1-10?
Any change in sleep pattern? Ability to concentrate?
Have you had any thoughts about hurting or killing yourself?
Have you ever engaged in self-harm behaviours?
What do you do to relieve stress?
Do you have an adult that you can talk to if you are having a
hard time? Who is that person?
Safety
Do you regularly use: seatbelts? Bike helmets? Appropriate
gear when snowboarding/skateboarding or other sports?
Does anyone at home own a gun?
Have you ever been the victim of violence at home, in your
neighbourhood or at school?
Has anyone ever hurt you or touched you in a way that was
hurtful or inappropriate
MacPeds Survival Guide 14-15 61
ADMISSION ORDERS (ADDAVID)
Admit: Admit to (Ward 3B/3C/NICU/L2N) under (staff name, Team #);
-If admitting while on-call overnight double check with your senior resident
which team that patient should be admitted to.
Admit to Team x under the care of [Night Staff name] with transfer of care to
[Team x Day staff] in the morning
Diagnosis: Confirmed or Suspected (eg. UTI with 2 dehydration)
Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going for surgery
or procedures) Sips Only, CF (Clear Fluids), FF (Full Fluids), Thickened Fluids
(dysphagia), Advancing Diet (NPO to sips to clear fluids to full fluids to DAT),
Diabetic Diet (indicate Calories eg. 1800 Kcal, 2200 Kcal), Cardiac Diet, TPN
etc. Include amount, frequency, rate if applicable.
Activity: AAT (Activity as Tolerated), NWB (Non-Weight bearing), FWB (Full
Weight bearing), BR (Bed Rest), BR with BRP (Bed Rest with Bathroom
Priviledges), Ambulation (Up in Chair Tid, Ambulate bid)
Vital Signs: VSR (Vital Signs Routine (HR, RR, BP, O2 sat, Temp. q 8-12
hours, q shift), VS q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (eg. Postural vitals, Neuro vitals)
Monitor: Accurate Ins & Outs (Surgery, volume status pts.)
Daily weights (eg. Renal failure, edematous, infants)
Investigations:
Hematology: CBC + diff, PTT/INR
Biochemistry: Electrolytes (Na
+
, K
+
,Cl
-
, HCO
3
-
), Urea, Creatinine, Ca
2+
,
Mg
2+
, PO
4
-
, glucose, CSF cell count, CSF protein and glucose
Microbiology: Urine R&M/C&S, Blood Cultures, CSF from LP for gram
stain, C&S. For this section just remember all the things you can culture:
CSF, Sputum, Urine, Feces, Pus from wounds, Blood
Imaging: CXR, CT, MRI, EKG, PFT, Spirometry
Consults: Social Work, Neurology, Infectious Diseases
Drugs
All medications patient is already on (Past), medications the patient needs right
now (Present), anticipate what the patient might need: prophylaxis, sleep,
nausea and pain (Future)
10 Patient Ps: Problems (specific medical issues), Pain (analgesia), Pus
(antimicrobials), Puke (anti-emetics, prokinetics, antacids), Pee (IV fluids,
diuretics, electrolytes), Poop (bowel routine), Pillow (sedation), PE
(anticoagulation), Psych (DTs), Previous Meds
Ensure you date and time your orders, put the childs weight and list any
allergies on the order sheet. Make sure you sign the order sheet and write your
name legibly and pager number.
MacPeds Survival Guide 14-15 62
PROGRESS NOTE: PEDIATRICS
General Pediatrics Ward (3B/3C) Clinical Clerk Progress Note
Date ! Always LEGIBLY note the Date, Time, Your Name and Pager Number !
Time
ID: age, sex with a history of (non-active/chronic issues/previously well) admitted
with (list active/acute issues for why patient is admitted)
eg. 18 mo ! previously healthy, admitted with a UTI and 2 dehydration
Subjective:
S: How patients night was (O/N) and how they feel that day and any new concerns
they have. What has changed since the previous note. Does the patient have any
new symptoms? How is the patient coping with the active symptoms,
progression, better/worse. If patient is non-verbal, ask the parents or patients
nurse. Remember to ask about: behaviour, activity, sleep, appetite, in and outs.
Objective:
O: General: Patient disposition (irritable, sleeping, alert), general appearance,
behaviour, cognition, cooperation, disposition
Vitals: HR, BP, RR, SaO
2
(on Room Air/NP with rate or %), Temp (PO/PR/AX),
weight (daily, with changes noted), Inputs (Diet, IV fluids and rate), Output (Urine
Output, BM/Diarrhea, Vomiting, Drains)
Vitals: Temp (PO or PR or Axilla?), HR, RR, BP, SaO2 (on room air? 24%? 2L?)
Focused P/E of system involved plus CVS, RESP, ABDO, EXT/MSK
common for hospitalized patients to develop problems in these systems
Investigations (Ix): New lab results, imaging or diagnostic tests/interventions
MEDS: reviewed daily for changes regarding those that are
new/hold/discontinued/restarted
Assessment & Plan\Impression (A/P or Imp):
Summarize what the new findings mean, what progress is being made
Improved? Stable? Waiting investigations/consult? Differential Diagnosis if
anything has been ruled in/out
Plan (A/P or I/P):
Issue (1) ! eg. UTI ! Day 2 of Empiric Abx, likely 14 day course
required. Awaiting culture and sensitivity
Issue (2) ! eg. Dehydration ! Intake still minimal, Urea mildly elevated,
clinically dehydrated therefore continue IVF at 50 ml/hr
Encourage oral fluids
Name, Designation (CC\PGY), Pager Number
Discussed with Dr. ________________
MacPeds Survival Guide 14-15 63
Documentation
Colleges and legislation define good documentation
Essential part of being a competent physician
Provides communication amongst team members and other physicians
Information documented in chart belongs to the patient - - you are the
caretaker
ALL notes in medical records should be written with expectation that
they will be viewed by the patient and/or their legal representative
PROFESSIONALISM
Colleges require a written, legible, medical record accompany patient
encounters, as a standard of practice
Hospitals require documentation be done in a timely manner
Documentation should provide a clear indication of physician's thought
process
Documentation in clinical notes should:
Be factual, objective, and appropriate to the purpose
Be dated and timed (preferably with 2400 clock)
Provide chronological information
Be written in a timely manner
Be legible, including signature and training level
Use only well-recognized abbreviations
Documentation should allow someone to determine:
Who attended the appointment (i.e. mother, father)
What happened
To whom
By whom
When
Why
Result
Impression
Plan
Late entries must be recorded as such
Phone contact should also be timed
MacPeds Survival Guide 14-15 64
Choose words carefully use:
Reported no.. VS denied
Declined VS refused
Avoid subjective and/or disparaging comments relating to the care provided
by other HCP.
Doubts about a colleague's treatment decisions should not be recorded in
medical records. Better to talk to your colleague instead.
Write only what YOU did or did not do. You cannot testify to the truth of the
event if no personal knowledge.
If negative event occurs, document what steps you took (who
notified, course of action). Again write no comments as to what
others did, will do, or said, etc. Notes may be written elsewhere
(not in chart) in the event of potential litigation, but these notes
are not protected,
NEVER change, tamper or add to a medical record. Any subsequent
additions or changes should be dated and signed at the time you make them,
to avoid undermining the credibility of any changes.
Do NOT later change an existing entry.
Do NOT black-out or white-out words or areas.
Do NOT insert entries between lines or along the margins of the chart
as these may appear to have been added later, casting doubt on their
reliability.
Do NOT add an addendum to the chart after learning of a legal action,
threat of a legal action or other patient complaint.
Poor charting may be perceived as reflecting less attention to detail, risking
the conclusion that care provided was poor.
MacPeds Survival Guide 14-15 65
Mandatory Reporting of Suspected Child Abuse and Neglect
During your clinical training in Pediatrics at McMaster, there is a possibility that you will
encounter a child in whom child abuse has been diagnosed or is suspected.
As a regulated health professional, you are required, under the provisions of the Child
and Family Services Act to immediately report to a Childrens Aid Society (CAS) any
suspicion that a child has suffered or is at risk of suffering from physical, sexual or
emotional abuse and/or neglect (which includes exposure to domestic violence). There
are serious legal and professional repercussions if a physician fails to meet this
obligation.
If you become concerned that a child has suffered or is at risk of suffering abuse or
neglect, you are encouraged to discuss this immediately with your preceptor so that it
can be determined if a report to CAS is warranted. While it is unlikely to occur, keep in
mind that it is an offense for someone in a position of authority to prevent another
person from making a report if that person believes that there is sufficient cause to do
so.
For more information:
http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/mandatoryreporting.pdf
GENERAL RULES re: DISCLOSING PHI (Personal Health Information) TO POLICE:
1. Must seek consent of the individual (or substitute decision maker) OR
2. Release information if required by law (i.e. mandatory gunshot wound reporting) OR
3. Release in compliance with a summons or order compelling production of the information; warrant -
only give out if disclosure details are provided
4. Police are not part of the circle of care and are not Health Information Custodians
The above information is described in s.43(1)(g) of PHIPA.
Please say to the police, "If you bring the proper documentation, then I'm happy to comply with your
request".
PHIPA allows health care providers to tell anyone that: an individual is a patient in the facility, individual's health
status (ie stable, serious), location of the facility (unless individual instructs otherwise), or to identify the deceased
MacPeds Survival Guide 14-15 66
DISCHARGE SUMMARY TEMPLATE: PEDIATRICS
Todays date
My name, designation (i.e. resident, clinical clerk)
Attending MD
Patient name, ID#
Copies of this report to: FD, pediatrician, pertinent consultants
Date of Admission:
Date of Discharge:
Start of dictation
ADMISSION DIAGNOSIS:
DISCHARGE DIAGNOSIS:
1., 2. etc
OTHER (non-active) DIAGNOSIS:
FOLLOW-UP: (appointments, pending investigations, home care)
DISCHARGE MEDICATIONS: (dose, frequency, route and duration)
SUMMARY OF PRESENTING ILLNESS:
- 1-2 line summary of childs presenting illness and reason for admission.
Refer to separately dictated note for full history and physical
examination of admission.
- Only if no admission dictation completed, indicate full history of
presenting illness (HPI), Past medical history, and initial physical
examination prior to Course in Hospital
COURSE IN HOSPITAL:
- Describe briefly the events and progression of illness while in hospital
including status upon discharge
- Details of drug doses used, IV rates, etc rarely required and difficult to
confirm as signing staff physician. Rather, say XXX required hourly
nebulized Ventolin for 5 hours after which the dosing interval was
extended to every three hours.
- If the child has multiple medical issues, this section can be done by
system (cardiovascular, respiratory, fluids and nutrition, ID,
hematological, CNS, etc)
- List complex investigations (with results) under a separate heading.
State your name, designation; Attending MD name Press 8 to end dictation,
and write down job # on face-sheet of chart
MacPeds Survival Guide 14-15 67
QUALITY DOCUMENTATION INITIATIVE
Discharge Summary Template
Diagnosis on Admission: Includes most responsible diagnosis for hospital admission
Diagnosis at Discharge: Includes most responsible diagnosis for hospital admission
as well as co-morbid conditions identified either at time of admission
or during the hospital admission as well as complications developed during course in hospital
Procedures: Includes a comprehensive list of procedures performed during hospital admission
for definitive treatment, diagnostic or exploratory purposes
Course in Hospital: Includes a detailed comprehensive list of critical events while in hospital,
complications, response to treatment
Discharge Medications: Includes a comprehensive list of medications, active at discharge,
dosage and mode of administration
Discharge Plans/ Follow-up: Includes a comprehensive list of appointments, treatments,
referrals, recommendations and follow-up including responsible physician(s), health care
team(s), or agency involved, including arrangements for aftercare
MacPeds Survival Guide 14-15 68
FLUID MANAGEMENT IN CHILDREN
3 Components to Fluid Management:
1. Maintenance
2. Deficit Replacement
3. Ongoing Losses Replacement
1. Maintenance
! Fluid and electrolyte requirements are directly related to
metabolic rate
! Holliday-Segar Rule - calculation of maintenance fluid
requirements using body weight for resting hospitalized
patients (based on 100 cc for each 100 kcal expended):
Body Weight Volume in 24 hours
Up to 10 kg 100 cc/kg/d (1,000 cc for 10kg child/day)
11- 20 kg 1,000 + 50 cc/kg above 10 kg
Above 20 kg 1,500 + 20 cc/kg above 20 kg
Weight (kg) Hourly Fluid Requirements
(Calculated by "4-2-1 rule)
0-10 kg 4 mL/kg/h
11-20 kg 40 mL/h + (2 mL/kg/h for each kg over 10
kg)
>20 kg 60 mL/h + (1 mL/kg/h for each kg over 20
kg)
! Insensible water losses = cutaneous + pulmonary water losses
which are calculated as ~ 300 500 cc/m
2
! During fluid management, we should assess factors affecting
insensible and/or urinary fluid losses
! Normal Na+ and K+ requirements 2 4 mEq/kg/day
! During fluid management, we should assess factors that affect
Na and K balance
! Adding 5% dextrose to maintenance solution prevents protein
catabolism
! Most commonly used solution in children:
D5 ! NS + 20 mEq/L KCl or D5W/NS + 20 mEq/L KCl
! D5 ! NS + 20 mEq/L KCl = 4 mEq/100cc/d Na+ and 2
mEq/100cc/d K+
! D10W: use in Neonates and Hypoglycemia
MacPeds Survival Guide 14-15 69
FLUID MANAGEMENT IN CHILDREN (Continued)
2. Deficit Replacement Assessment Includes:
Severity:
! Represents the percentage of body weight loss, acute weight
loss reflects losses of fluid and electrolytes rather than lean
body mass
! Most commonly estimated based on history and physical exam
! See table on next page
! To calculate fluid deficit: % x 10 x body weight (pre-illness)
Type:
! A reflection of relative net losses of water and electrolytes
based on serum Na+ or osmolality
! Important for pathophysiology, therapy and prognosis
! Affects water transport between ICC and ECC
! 70 80% pediatric dehydration is isotonic
Type of
Dehydration
Electrolyte Status Clinical Features
Hypotonic or
Hyponatremic
Serum Na+ < 130 mEq/L,
Serum Osm < 270
Exacerbated signs of
dehydration
Risk of seizure
Isotonic or
Isonatremic
Serum Na+=130-150 mEq/L,
Serum Osm 270 300
Hypertonic or
Hypernatremic
Serum Na+ > 150 mEq/L,
Serum Osm >300
Decreased signs of
dehydration
Irritable, increased
tone and reflexes
MacPeds Survival Guide 14-15 70
FLUID MANAGEMENT IN CHILDREN (Continued)
Assessing Dehydration: Severity
Patient Presentation Mild Moderate Severe
Age
% Weight Loss
Less than 1 year:
Less than/equal
to 5%
Greater than 1
year: <= 3%
Less than 1 year:
10%
Greater than 1
year: 6%
Less than 1 year:
15%
Greater than 1 year:
9%
Heart Rate
Blood Pressure
Normal
Normal
Mild tachycardia
Normal
(orthostasis)
Moderate
tachycardia
Decreased
Respiratory Rate Normal Normal Increased
Skin
Capillary refill
Elasticity (less than 2 years)
Anterior fontanel
Mucous membranes
< 2 seconds
Normal
Normal
Normal / Dry
2 - 3 seconds
Decreased
Depressed
Dry
> 3 seconds
Tenting
Depressed
Dry
CNS
Mental Status
Normal
Altered
Depressed
Eyes
Tearing
Appearance
Normal / Absent
Normal
Absent
Sunken
Absent
Sunken
Laboratory Tests
Urine
Volume
Specific gravity
Blood
Blood Urea Nitrogen
Small
1.020
Upper normal
Oliguria
1.025
Elevated
Oliguria-anuria
Maximal
High
Signs of dehydration may be less evident or appear later in hypernatremic dehydration;
conversely, they may be more pronounced or appear sooner in hyponatremic dehydration
MacPeds Survival Guide 14-15 71
FLUID MANAGEMENT IN CHILDREN (Continued)
Labs:
! Helpful in evaluation of Type and Severity of dehydration
! May need to start therapy before lab results available
! CBC for hemoconcentration, infection, source of dehydration
! Electrolytes (Na
+
, K
+
, Cl
-
, HCO
3
-
)
! BUN, Cr increased in severe dehydration
! Blood gas and HCO
3
-
for metabolic acidosis, may need to
calculate Anion Gap (AG) = [ (Na
+
+ K
+
) (Cl
-
- HCO
3
-
)]
Normal AG = 12 4
! Urine R&M, concentrated urine in dehydration, infection
Monitoring Ongoing Dehydration\Rehydration Response:
! Clinical response to treatment
! HR, BP, Cap refill, LOC, Urine output
! As indicated: cardioresp monitor, CVP, ECG
! Labs as indicated: electrolytes, urine specific gravity,
serum / urine Osm
! Repeated careful weight measurement
! Accurate INS and OUTS including stool volume & consistency
2. Deficit Replacement Oral Rehydration Therapy (ORT):
! First-line treatment for Mild to Moderate dehydration
! Requires close monitoring and compliance of patient and
parents
! Contains balanced amounts of sodium and glucose
! Basic treatment is replacing the deficit over 4 6 hours and
replacing ongoing losses (eg. Diarrhea) by ORT
! Initial rates of ORT:
! Mild:1 cc/kg/5 mins
! Moderate 2cc/kg/5 mins
MacPeds Survival Guide 14-15 72
Solution Glucose
(mEq/L)
Na
(mEq/L)
K
(mEq/L)
Base
(mEq/L)
Osmolality
WHO 111 90 20 30 310
Rehydrate 140 75 20 30 310
Pedialyte 140 45 20 30 250
Pediatric
Electrolyte
140 45 20 30 250
Infantlyte 70 50 25 30 200
Naturlyte 140 45 21 48 265
MacPeds Survival Guide 14-15 73
FLUID MANAGEMENT IN CHILDREN (Continued)
2. Deficit Replacement Parenteral Therapy (IV):
! Indications: Severe dehydration, patients who fail ORT due to:
vomiting, refusal or difficulty keeping up with losses
! Preferable site is IV, if unable to start IV use IO
! Consists of 3 phases:
(i) Initial Therapy
o Goal: expand ECF volume to prevent or treat shock
o Solution: isotonic saline (0.9% NS or RL) in all forms of
dehydration, never use hypotonic solution!!!
o Bolus 10 20 cc/kg of N/S ( or RL) over 15-20 mins initially,
may be repeated until patient is hemodynamically stable, if
unstable, call Peds 1000!
o Rapid Rehydration (eg. 20-40 cc/kg bolus + ORT) " no
evidence
o If hypokalemic: start K
+
when patient voids (normal renal
function). Note: no K
+
in bolus!
(ii) Subsequent Therapy
o Goal: continue replacement of existing deficit, provide
maintenance and electrolytes, replace ongoing losses
o Solution: D5 ! NS + 20 mEq/L KCL or D5NS + 20 mEq/L
KCL in isotonic dehydration
o Deficit Replacement Time: usually over 24 hours "
! deficit in first 8 hours, second ! deficit over next 16 hours
o Subtract boluses from deficit calculation
o Source of Electrolyte Losses: 60% ECF and 40% ICF
! For every 100 cc water lost, electrolyte losses:
o Na
+
: 8.4 mEq/L / 100cc
o K
+
: 6.0 mEq/L / 100cc
o Cl
-
: 6.0 mEq/L / 100cc
(iii) Final Therapy
o Return patient to normal status and to normal feeding
MacPeds Survival Guide 14-15 74
FLUID MANAGEMENT IN CHILDREN (Continued)
3. Ongoing Losses
Replace" With"
Gastric Losses (Vx) ! NS + 10 20 mEq/L KCl
Stool or Intestinal
losses (Diarrhea)
Add HCO
3
-
to
! NS + 10 20 mEq/L KCl
CSF losses 0.9% NS
Urine Output As indicated
Losses due to Burns Increase fluid administration (Parkland)
Isotonic Dehydration
See previous steps
Rehydrate over 24 hours
Hypotonic Dehydration
Degree of dehydration may be overestimated
May need immediate circulatory support
Calculate fluid losses as above
Calculate electrolyte losses
Calculate Na
+
to correct Na
+
to 130 mEq/L using the following
formula (as long as Na
+
> 120 mEq/L)
o (Desired Na
+
Measured Na
+
) x 0.6 x weight (kg)
Replace losses over 24 hours (if acute losses!)
Max increase 1 mEq/L
Hypertonic Dehydration
Bolus by NS or RL as indicated
Avoid electrolyte free solutions
Calculate water and electrolyte losses
Replace deficit slowly over 48 hours
Monitor serum Na
+
q2 4hours (should not fall > 0.5 mEq/L/h,
max 10 mEq/L/24h) and change fluids according to Na
+
drop
Usually seize as Na
+
drops, rather than as increases
If seizures or signs of increased ICP, treat with mannitol
MacPeds Survival Guide 14-15 75
Comparison of IV Solutions
IV Solution Na
+
(mEq/L)
K
+
(mEq/L)
Cl
-
(mEq/L)
Dextrose
(g/L)
Osmolarity
(mOsm/L)
Sodium Chloride 0.45% 77 0 154
Sodium Chloride 0.9% (0.9 NaCl, NS) 154 154 0 308
Sodium Chloride 3% 513 0 1030
Dextrose 5% 0 50 250
Dextrose 5% Sodium Chloride 0.2%* (D5 0.2NS) 39 50 320
Dextrose 5% Sodium Chloride 0.45% (D5 !NS) 77 77 50 405
Dextrose 5 % Sodium Chloride 0.9% 154 50 560
Dextrose 10% 0 100 505
Dextrose 10% Sodium Chloride 0.2%* 39 100 575
Dextrose 10% Sodium Chloride 0.45%* 77 100 660
Dextrose 10% Sodium Chloride 0.9%* 154 100 813
Dextrose 3.3% Sodium Chloride 0.3% (" * #) 51 51 33.3 273
Lactated Ringers 130 4 109 0 273
Also contains Calcium (Ca
2+
) 1.5 mmol/L, and Lactate (HCO
3
-
) 28 mmol/L
*These solutions are not commercially available
Commonly used solutions are highlighted
MacPeds Survival Guide 14-15 76
IV solution Na (mEq/L) K (mEq/L) Cl (mEq/L) % Electrolyte
Free Water
(EFW)*
H
y
p
o
t
o
n
i
c
0.2% NaCl in
D5W
34 0 34 78
0.45% NaCl
in D5W
77 0 77 50
Lactated
Ringers
130 4 109 16
0.9% NaCl in
D5W (ISOTONIC)
154 0 154 0
Guidelines for Prescribing Maintenance IV Fluids in Children
These are general guidelines for ordering maintenance IV fluids (IVF) only, and do not apply to resuscitation or complicated fluid and electrolyte
disorders. Seek additional advise/appropriate consultation in the event of fluid and electrolyte abnormalities.
Consider IV fluids as DRUGS - individualize prescriptions daily according to objectives, and monitor for potential side effects.
Be aware that the commonest side effect of IVF therapy is HYPONATREMIA, particularly in patients at risk, and if hypotonic solutions are used
Step 1:
Determine IV fluid rate, according to maintenance fluid requirements, and replacement of deficit or ongoing losses
(Total Fluid intake (TFI). In general maintenance fluid rate is calculated by the 4:2:1 guideline, but should be
individualized according to the clinical condition and patient assessment
Step 2: The choice of fluid is dependent the individual patient.
Consider ISOTONIC IVF for the following patients:
CNS disorder, Diabetic ketoacidosis
Patients at risk of hyponatremia: acute infection, post-operative patients
and burns, Plasma Na < 138
Add K
+
to provide 1-2 mEq/kg/day, if patient has urine output
Add Dextrose to prevent hypoglycemia/ketosis (exceptions: hyperglycemia,brain injury)
Consider HYPOTONIC IVF for the following patients:
Patients with an EFW deficit - e.g. hypernatremia, ongoing EFW losses
(renal, GI, skin)
Patients with established 3rd space overload - e.g CHF, nephrotic
syndrome, oliguric renal failure, liver failure
Limited renal solute handling indicated - e.g. neonatal population,
hypertension
Step 3: MONITORING while on IV fluid Measure and record as accurately as possible
Clinical status: hydration status,urine
output, ongoing losses, pain, vomiting,
peripheral edema, and general well-being.
Daily weights
Reassess TFI, indications for and fluid
prescription at least every 12 hours.
Fluid balance: must be assessed at least every
12 hours
Intake: All IV and oral intake (including
medication). Ensure this matches desired TFI.
Output: all losses (urine, vomiting, diarrhea etc.)
Labs:
Serum Electrolytes - at least daily if primary source
of intake remains IV, or more frequently depending
on clinical course, or in the presence of documented
electrolyte abnormality.
Urine osmolarity/sodium and plasma osmolarity as
indicated, for determining etiology of hyponatraemia.
Weight
(kg)
ml/hour
0-10 4/kg/hour
11-20 40 + (2/kg/hr)
>20 60 + (1/kg/hr)
*Based on a sodium plus potassium concentration in the aqueous phase of plasma of 154mEq/L, assuming that
plasma is 93% water with a plasma sodium of 140 mEq/L and a potassium concentration of 4 mEq/L
Version date : April 2011
MacPeds Survival Guide 14-15 77
Developmental Milestones
Gross Motor Fine Motor Language Social & Self help Red Flags
0-1
month
-Moves head from side
to side on stomach
-Usually flexed posture
(prone position legs are
under abdomen)
-Keeps hands in tight
fists
-Brings hands within
range of eyes and
mouth
-Turns toward familiar
sounds & voices
-Recognizes some
sounds
-Recognizes the scent of
his own mother's breast
milk
-Prefers the human face to
all other patterns
- Sucks poorly
- Doesn't respond to bright
lights or loud noise blink
when shown bright light
- Seems stiff or floppy
Achieved
2
months
-Hips not as flexed
(prone position legs not
under abdomen)
-Head control improving
(pull to sit)
-Hands open most of
the time
-Cooing (vowel-like
sound- ooooh, ah)
-Increases vocalization
when spoken to
-Smiles
-Face is expressive
- Doesn't smile at the sound
of your voice by 2 months
- Doesn't notice her hands
by 2 months
-Not tracking objects
Achieved
3
months
-Lift head when held
-Lift head & chest when
on tummy
-Grasps and shakes
hand toys
-Holds hands open
-Chuckles
-Begins to imitate some
sounds
-Turn toward the sound of
a human voice
-Smile when smiled at
- Doesn't hold objects
- Doesnt smile
- Doesnt support head
Achieved
4
months
-No head lag in pull to
sit
-Rolls from front to back
-Reaching & grasping
-Brings toys to mouth
-Looks at objects in
hand
-Shows excitement w/
voice & breathing
-Increases vocalization
to toys & people
-Smiles at self in mirror
-Increases vocalization to
toys & people
- Doesn't reach for and
grasp toys by 3 - 4 months
- Doesn't babble
- Always crosses eyes
Achieved
5
months
-No head lag
-Head steady when
sitting
-May roll back!front
-Holds two objects in
both hands when
placed simultaneously
-Mimics sounds &
gestures
-2 syllable sounds (ah-
goo)
-Babbles to get your
attention
-Able to let you know if
hes happy or sad
-Doesnt roll over
-Doesnt lift head while on
tummy
Achieved
6
months
-Sits w/ hands on legs
(propping self up)
-Bears full weight on
legs if held standing
-Transfers object from
1 hand to the other
-Reaches after dropped
toys
-Expresses displeasure
with non-crying sounds
-Knows family from
strangers
-Pats at mirror image
-Pushes adult hand away
-Babe makes no sounds or
fewer sounds, especially in
response to you
-Doesnt reach for things
Achieved
7
months
-Bounces when held
standing
-Assumes crawling
position
-Reaches with one
hand
-Bangs toys on table
surface
-Begins responding to
"no"
-Starts using consonants
(da, ba, ga)
-Enjoys social play
-Interested in mirror
images
-Reaches with 1 hand only
-One or both eyes
consistently turn in or out
-Refuses to cuddle
Achieved
8
months
-In sitting, reaches
forward and can return
to sitting up erect
-Holds own bottle
-Starts eating finger
foods
-Responds to own name
-Babbles chains of
consonants
-Plays peek-a-boo
-Anticipates being picked
up by raising arms
-Seems very stiff with tight
muscles
-Not babbling by 8 months
Achieved
9
months
-Gets to sitting position
alone
-Pulls to stand
-Immature pincer grasp
(thumb onto side of
index finger)
-Uses mama or
dada nonspecifically
-Waves bye
-Cant push up on arms
while on tummy
-Cant sit alone
-Cant bear weight in
MacPeds Survival Guide 14-15 78
-Crawling -Plays peek-a-boo standing position
Achieved
10
months
-Pulls to stand
-Cruises with 2 hands on
a rail or furniture (for
support)
-Grasps bell by handle
-Points at a bead/small
object
- Jargons with inflection
- Performs 1 nursery
gesture on verbal
command
Imitates nursery gestures:
-Pat-a-cake
-Waving
-So big
-No special relationship w/
any family members
-Isnt moving around room
in some fashion i.e. rolling,
creeping
Achieved
11
months
-Stands momentarily
-Walks with one hand
held
-Mature pincer ! can
pick up tiny objects
with ends of thumb and
index finger
-One word with
meaning (e.g. dada)
-Understands simple
request with gesture
-Extends arm & leg to
help when being dressed
-No stranger anxiety
-Doesnt seek social
interaction with familiar
people
Achieved
12
months
-Walks a few steps
-Stands independently
-Creeps upstairs
-Mature pincer grasp
-Starting to point
-Helps turn pages in a
book
-2-3 words w/ meaning
-Uses exclamations
such as "Oh-oh!"
-Cries when mother or
father leaves
-Repeats sounds or
gestures for attention
-Doesnt know their name
-Not crawling or moving
forward
Says no single words
Achieved
Developmental Milestones: 1 - 5 Years:
Skill 12 mo 15 mo 18 mo 2 yrs 3 yrs 4 yrs 5 yrs
Walking
Walking few
steps, wide
based gait,
clumsy
Walking few
steps, wide
based gait,
clumsy
Running,
unstable
Fall if trying
to pivot
Running well
Jumps with 2
feet on floor
Broad jumps
Stands on 1 foot
for 2 seconds
Walks on tip toes
Tandem gait
forward
Skips alternating
feet
Hops on 1 foot
Age Achieved
Stairs
Creeps up-
stairs
Creeps up-stairs
Crawls down-
stairs very slow
& careful
Walk up-stairs
w/ hand held
2 feet per step
Walks up
stairs alone
2 feet per step
Alternates feet
while walking up
stairs
Alternates feet
while walking down
stairs
Jumps off last steps
Balances on 1
foot for > or equal
to 10 seconds
Age Achieved
Gross Motor
Stands well
Climbs up
onto a chair
Climbs up on a
chair
Throws ball +/-
falling over
Sit on chair
Walks & pulls
object
Kicks ball
Throws ball
overhand
Pedals tricycle Stands on 1 foot for
4 seconds
Bicycle +/-
training wheels
Age Achieved
Fine Motor
Pincer grasp
Releases object
if asked
Stacks 2 blocks Stacks 3-4
blocks
Puts shapes on
to board
Stacks 5-7
blocks
Stacks 9 blocks
Imitates bridge
Stacks 10 blocks
Opposes fingers to
thumb in sequence
Does buttons up
Age Achieved
Drawing
Crayon in
mouth
Linear scribbles Circular
Imitates
stroke
Copies Circle
3yrs
Copies cross
Copies square Copies triangle
MacPeds Survival Guide 14-15 79
Marks paper Scribble 3.5yrs Prints name
Age Achieved
Expressive
Speech
2-3 words 5-10 words 20 - 50 words 100-200
words
2 - 3word
combo
5-8 words together
Uses: I, me, u
(pronouns)
Answers
W questions
Past tense
Prepositions (behind,
on, under)
Tells stories
Defines words by
use- what is a
ball?
Age Achieved
Receptive
Speech
1 command
w/ gestures
1 command w/
out gestures
5 body parts
5 Common
objects
2 step
command
Knows Age
Knows their Sex
Full name
5-10 numbers by
rote
3-4 step instruction
Counts 10 pennies
Follows group
direction
Age Achieved
Eating
Eats cheerios
Sipping cup
Spoon level,
w/ solids
Spoon level,
w/ semi-solids
Eats neatly Eats neatly Spreads peanut
butter on bread
Age Achieved
Dressing
Plays peek-a-
boo
Helps to
remove cloths
Start taking
off cloths
Takes cloths
all off
Raise arms
Supervised dressing; Dress alone
Unbuttons clothes
Buttons clothes up
Age Achieved
Cognitive/
Adaptive
Kisses on
request
Should have
object
permanence
Seeks help w/
gestures
Use cause and
effect toys
Parallel play
Folds paper
Unscrews
tops
Plays simple
games
Listens to stories
Group play
Imaginary friend
4 colours
Knows: same,
biggest, tallest
Knows alphabet
Sort by size
Label shapes,
classify object
MacPeds Survival Guide 14-15 80
MacPeds Survival Guide 14-15 81
MacPeds Survival Guide 14-15 82
!""#$%&'(%)$*+ -(./0 !$1)0"'(%)$
Note: For premature infants, administer vaccines according to chronological or
cumulative age, not corrected age
Immunization Schedules:
http://www.health.gov.on.ca/en/public/programs/immunization/docs/schedu
le.pdf
Immunization Guide:
http://www.phac-aspc.gc.ca/publicat/cig-gci/pdf/cig-gci-2006_e.pdf
MacPeds Survival Guide 14-15 83
NEONATOLOGY
MacPeds Survival Guide 14-15 84
St Joes NICU common terms and definitions list
As and Bs- (apnea and bradycardia) defined as a cessation of breathing >20 sec or pause in breathing
associated with decrease in oxygen saturation <85% or HR <100 or change in color or tone. Or just the presence
of bradycardia.
Will be reported as self resolved or requiring stimulation.
Common in preterm infants however must always rule out sepsis.
B/R- Breast feeding.
BLES- Bovine surfactant, medication give for treatment of RDS (Respiratory distress syndrome) given via ETT
(endotracheal tube) dose 5cc/kg. May also be used in MAS (meconium aspiration syndrome) or severe
pneumonia.
CPAP- Continuous positive airway pressure, non invasive form of ventilation providing continuous PEEP
(positive end expiratory pressure) used to keep airways open and prevent airway collapse. Used in a multitude
of settings.
CLD (chronic lung disease) - formerly known as BPD (bronco pulmonary dysplasia) - CLD is usually defined
as oxygen dependency at 36 weeks postmenstrual age (PMA) or 28 days postnatal age (PNA), in conjunction
with persistent clinical respiratory symptoms and compatible abnormalities on chest radiographs .
Gavage- form of feeding, by where an OG tube is inserted into the stomach (placed clinically) and a feed is
given by gravity or over a period of time by pump. Prior to the feed the nurse will generally draw back to see if
there is any residual feed in the stomach. Reported as 0/37, scant/37 or 5/37 where the first number represents
the volume of the residual and the second number the volume of the feed given. Colour of the residual is
important especially when evaluating for NEC (necrotizing enterocoloitis)
GBS (group B streptococcus) organism that is a common cause of neonatal infection, all women should be
screened at 35-37 weeks and important to note at deliveries or on evaluation of infants < 7 days of age.
Histogram- continuous monitoring of oxygen saturations over 1-2 hrs, done in either prone or supine position.
Reported as an average of the time period.
Reported as greater than 90 over 90, first number represents the saturation the second the percentage of the time
that babys actual O2 saturation is over that saturation.
Normal for preterms 90 over 90
For preterms greater than 30 days and diagnosed with CLD 85 over 90.
*Normal values may vary with new research.
IDDM- infant of a diabetic mother. Maternal diabetes can cause a multitude of neonatal complications, most
commonly hypoglycemia.
I/T ratio- immature to total ratio, used in the evaluation of sepsis. Calculated by taking the total number of
immature WBCs seen on manual differential (bands, myelocytes, metomyleocytes, and/or promyelocytes)
divided by the total number of neutrophils plus the immature WBCs.
Immature WBCs/total neutrophils + immature WBCs
IUGR (intrauterine growth restriction) - defined as symmetric or asymmetric, if symmetric both head
circumference and weight are less than the 3
rd
percentile if asymmetric only the weight is <3
rd
percentile.
NEC (necrotizing enterocolitis) - Gut infection, characterized by feeding intolerance, bilious residuals,
abdominal distension, bloody stools, with other signs and symptoms of sepsis.
MacPeds Survival Guide 14-15 85
Nippling- synonymous with bottle feeding, reported as infant nippled 20 (infant took 20cc by bottle)
RDS- (Respiratory Distress syndrome) common in preterm infants or infants of IDDM (infant of a diabetic
mother) due to surfactant deficiency.
TPN- (Total Parenteral Nutrition)- form of nutrition given by IV, contains glucose and varying amount of Na
+
,
K
+
, Ca
2+
PO
4
3-
, lipids and amino acids, generally used when infants cannot tolerate feeds.
TFI- (Total fluid index) volume of fluid that an infant receives per day, either enteral or parenteral. Reported in
cc/kg/day. i.e. TFI of 60 cc/kg/day in a 3.0 kg term infant is:
60 x 3/24= 10 cc/hr or 30 cc q3h
Some useful definitions and normal values for term newborns:
Neonate: less than or equal to 28 days
Infant: 28 days to 1 year
Child: >1 year
Birth
-Average birth weight: 3.5 kg
-Average birth length: 50 cm
-Average birth head circumference: 35 cm
Weight loss
-Average weight loss in first week is 5-10% of birth weight
-Max weight loss in first 48 hrs: 7%
-Max weight loss in first week: 10%
Growth
-Return to birth weight by 14 days
-Infants double their birth weight by 5-6 months
-Infants triple their birth weight by 12 months
-Head circumference increases by 12 cm in first year of life
MacPeds Survival Guide 14-15 86
PROGRESS NOTE: NEONATES (LEVEL 2 NURSERY)
Date Time
ID: Baby boy (surname)
Born at 33
5/7
(i.e. 33 weeks and 5 days) gestational age
Day of life (DOL): 12
Corrected Gestational Age: 36
3
wks (33
5
+ 12 days)
Birth weight: 2680g
Todays weight: 2550g (! 10 g from yesterday)
Brief problem list
e.g. 1. Prematurity
2. Apnea of prematurity
3. Unconjugated hyperbilirubinemia
4. Suspected NEC
S/O: Feeds: frequency, amount, what? (EBM? Formula? Supplement?), method,
regurgitation/vomiting, breast feeding?
Stool/urine pattern
Other signs/symptoms you may be following (e.g. bilirubin)
Behaviour: Settles easily? Irritable? Jittery? Interaction? Sleep? Handling?
Episodes of Apnea/Bradycardia? (As and Bs)
IV fluid/rate, urine output
Medications and other treatments (i.e. phototherapy)
Recent labs and investigations.
A: Summarize active issues. Stable? Awaiting further investigations/consult
Differential Diagnosis
P: Outline plan by issue: include investigations, treatment, discharge plans
.
eg. Resolving NEC ! increase feeds slowly, starting at EBM 5cc q3h
Jaundice ! double phototherapy, recheck bili in am.
Name, Designation (CC\PGY), Pager Number
Discussed with Dr. ________________
MacPeds Survival Guide 14-15 87
NICU / L2N DISCHARGE SUMMARY TEMPLATE
Name of person dictating:
Patient Name:
Patient Identification Number:
Admission /Transfer to L2N Date:
Discharge Date:
Copies to: Family physician
Referral physician
Follow-up pediatrician
Health records
All health care professionals involved
Problems on Admission: Current Problems:
1. 1.
2. 2.
3. 3.
Birth Parameters Discharge Parameters
Gestational age: Corrected and chronological age:
Weight:____ g (%ile) Weight:____g
Length: _____ cm (%tile)
Head circumference:____cm (%ile) Head circumference:_____cm
Maternal History and Delivery:
____________was born at McMaster University Medical Centre/elsewhere on (date) at
___ weeks gestational age to (parents full names). (Mothers name) is a (age) G T P
A L woman whose antenatal screens were: rubella (immune/nonimmune), VDRL
(reactive/nonreactive), hepatitis B serum antigen (-/+), HIV (-/+ __ GA), GBS (+/- at __
GA) and blood group __. This pregnancy was uneventful/complicated by__________.
(Celestone was administered at __ weeks gestation.) Membranes ruptured __hours
prior to delivery. The infant was born vaginally/caesarian section. Apgar scores were
__ at one minute and __at five minutes. (Insert post-delivery management.) He/she
was appropriate/small/IUGR for gestational age with dysmorphic/ no dysmorphic
features seen. The infant was admitted to the NICU/L2N and had the following
problems.
Cord gases were normal, OR ____.
** If the infant had a prolonged stay in the NICU, refer here to NICU discharge
summary, and do NOT repeat all these details.**
Include only applicable headings below.
MacPeds Survival Guide 14-15 88
Respiratory Distress Syndrome/Bronchopulmonary Dysplasia:
The infant received __doses of BLES. (Name) was ventilated for __ days when he/she
was extubated to NPCPAP. (Insert any complications: HFO, chest tubes, nitric oxide.)
He/ she received (number) courses of dexamethasone. He/she was placed on low
flow oxygen on __day of life. He/she is presently requiring (therapy). The last chest x-
ray on (date) showed _____. The most recent blood gas shows __.
Apnea of Prematurity:
(Name) was loaded with caffeine citrate on __day of life. He/she is presently having
__apneas per day/(or) is apnea free. Caffeine was discontinued on (date).
Patent Ductus Arteriosus/Cardiovascular Anomalies:
The infant was treated/not treated with a course of Indomethacin on (date) for a patent
ductus arteriosus that presented clinically/(or) was confirmed on echocardiogram.
(Describe current status of murmur). (Repeat echocardiogram? Other cardiac
anomalies? Follow-up?)
Hyperbilirubinemia:
Mothers blood type is __and infants blood type is __. Serum bilirubin peaked at
__mmol/L at __day of life. The infant received __days of phototherapy.
Hematology:
(List any blood product transfusions). The most recent CBC on (date) showed a
hemoglobin of__, WBC of__x 10
9
/l, a platelet count of __,000 and no left shift.
Sepsis:
Cultures drawn following delivery were negative/(or) positive for (name of organism).
The infant received a __(# of days) course of (name of antibiotics). Due to clinical
deterioration(s) the infant had a partial/(or) full septic workup(s) on (date) which grew
(name of organism) and was treated with (name of antibiotic). During the neonatal
course the infant had__ episodes of sepsis which were culture negative/positive (state
organism(s) if identified)
Neurological:
Cranial ultrasound(s) done on __day of life showed___(include date and result of most
recent ultrasound). A follow-up ultrasound is recommended in __weeks.
Retinopathy of Prematurity (ROP):
Routine eye examinations were performed. The most recent examination on (date)
revealed zone__stage __ with no plus disease. A follow-up exam is strongly
recommended in __weeks to exclude progressive ROP. A follow-up eye appointment
has been made at the eye clinic at McMaster for (date and time).
MacPeds Survival Guide 14-15 89
Neonatal Abstinence Syndrome (NAS):
The infant was monitored with Finnigan Scoring from ___ (date) to ___(date) for
withdrawal symptoms due to maternal use of ___ (list substances applicable:
oxycodone / methadone / cocaine, etc) with a peak Finnigan score of ___(#) reached
on ___ (date). The infant's mother (was / was not) part of a Methadone program during
pregnancy. Maternal urine drug screen at presentation to L&D on ___ (date) was
positive for ___ (list substance/s). The infants urine was collected for drug screening
on ___ (date) and was positive for ___ (list substances). The infants meconium & hair
(was / was not) sent for drug screening. This infant (did / did not) require morphine
treatment for withdrawal symptoms initiated on ___ (date) and discontinued on ___
(date), up to a maximum dose of ___ mg/kg/day on ___ (date). This infant (did /did
not) require treatment with phenobarbital initiated on ___ (date) at a dose of ___ (#),
which was equal to ___ (#) mg/kg/day. The infant (was / was not) discharged on
Phenobarbital ___ (dose), which is equal to ___ (#) mg/kg/day. The infants weaning
course off morphine was ___ (describe: quick / slow / a struggle weaning off final
doses) and was complicated by ___ . Final Finnigan scoring in the 48 hrs prior to
rooming in were in the range of ___ (#) to___ (#) . There (was / was not) breastfeeding
restrictions due to the maternal use of ___ .
Fluids, Electrolytes and Nutrition:
Enteral feeds were started on __day of life and the infant achieved full enteral feeds on
__day of life. Presently, the infant is receiving (TPN and/or__cc q__hourly of
expressed breast milk fortified with __package of human milk fortifier to __mls of EBM
(or) name of formula by gavage, breast and/or bottle) for a total fluid intake of
__cc/hour. This provides __cc/kg/d or kcal/kg/d based on the current weight. On
(date) the serum sodium was __mmol/L, calcium was__mmol/L, and phosphate was
__mmol/.
Social:
Social worker ___ (list name) was involved with this infant and his/her family during the
NICU stay due to ___ (reason). CAS (was / was not) involved with this family due to
concerns of ___ . The infants CAS worker is ___ (list workers name) who can be
reached at ___ (number & extension). At the time of discharge, the case with CAS will
remain (open / closed). This infant will be going home to the care of ___ (list if it is:
biological parents, kinship, foster care, adoption AND name/s of the individual /s).
Immunizations:
1. Synagis (eligibility and date received or required and reference #).
2. Pentacel (date received or required),
3. Prevnar (date received or required).
4. Hepatitis B Immunoglobin/Vaccination (date received or required).
Discharge Medications: Include iron, calcium/phosphate, vitamins
MacPeds Survival Guide 14-15 90
Neonatal Screens:
1. Newborn Screen was completed on (date).
2. Hearing screen was performed on (date) as per Ministry of Health guidelines. A
pass/fail was obtained for one/both ears.
(Name) is being transferred to (hospital/) under the care of (physician) until he/she can
be discharged home OR (Name) is being discharged home to the care of his
parents/foster parents.
Follow-up
The infant requires follow-up for retinopathy of prematurity and cranial ultrasounds as
well as (indicate any follow-up required including growth and development,
appointments, etc.)
Thank you for accepting the care of this infant.
Name, Designation (CC\PGY), Pager Number
Dictating For Dr. (Name of Paediatrician/Neonatologist)
MacPeds Survival Guide 14-15 91
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MacPeds Survival Guide 14-15 92
NEONATAL RESUSCITATION DRUGS
1 kg
< 30 weeks
2 kg
30-36 weeks
3 kg
> 36 weeks
Epinephrine
1:10,000
0.1 mg/ml
q3-5 minutes
IV Route
(Preferred Route) (0.01mg/kg)
0.1 ml 0.2ml 0.3 ml
ETT Route
(0.1 mg/kg)
1 ml 2 ml 3 ml
Sodium Bicarbonate 4.2% IV
0.5 mmol/ml (2 mmol/kg)
For Prolonged Arrest
4 ml
8 ml
12 ml
Naloxone IV or IM
0.4 mg/ml (0.1 mg/kg)
Contraindicated in narcotic dependent mothers
0.25 ml
0.5 ml
0.75 ml
Volume Expanders
Normal Saline (NS, 0.9 NaCl)
Packed Red Blood Cells
10 ml
10 ml
20 ml
20 ml
30 ml
30 ml
Glucose (D10W) IV Bolus
200 mg/kg
For documented hypoglycemia
2 ml
4 ml
6 ml
MacPeds Survival Guide 14-15 93
NICU NUTRITION GUIDELINES
ENTERAL FEEDING IN NICU
Method of Feeding (By Age)
< 32 weeks 32-34 weeks 34-36 weeks 36-40 weeks
Gavage
Yes Yes If indicated Not usually
Breast
Individual
Assessment
1-2 q shift Yes Yes
Bottle
1-2 q shift
Near 34 wks
Yes Yes
Ad lib
Minimum feed
Vol (mL)/ Time (hr)
Yes
FEEDING HUMAN MILK IN NICU
Human milk is the Feeding of Choice for All Infants in NICU
Expressed Breast Milk (EBM)
All infants should be established on feeds of EBM when available. If EBM is not available or not
indicated then formula may be used either as a supplement to EBM or as the sole source of
nutrition
MacPeds Survival Guide 14-15 94
NICU NUTRITION GUIDELINES
ENTERAL FEEDING IN NICU
Initiation and Advancement of Enteral Feeds (By Birth Weight and Age)
Infants < 1500 grams Birth Weight: Pre-calculated guidelines for each 100g weight category available
in the NICU. Level 2 will have pre-calculated guidelines for babies >1100g
< 750 grams 750 999 g
1000 - 1249 g 1250-1500 g
Initiate Trophic Feeds:
(10-15 ml/kg/d)
By 12-24 hr of age By 12-24 hr of age By 6-12 hours By 6-12 hours
Volume/Frequency
Tropic Feeds
1 ml q3-4 hr X 3 days 1 mL q 2-3 hr x 2d 1-2 ml q2 hr x 1d 1-2 mL q2h x 1d
Nutritional Feeds -
Timing
Day 4 feeds Day 3 feeds Day 2 feeds Day 2 feeds
Initiation Volume 15-20 mL/kg/d 15-20 ml/kg/d 25-30 mL/kg/d 25-30 mL/kg/d
Feeding Interval 2 hourly 2 hourly <1250g 2 hourly
>1250g 3 hourly
3 hourly
Rate of Increase 15-20 mL/kg/d x 3d
Then 20-25 mL/kg/d
15-20 mL/kg/d x 3 d
Then 20-25 mL/kg/d
20-25 mL/kg/d 20-25 mL/kg/d
Donor milk is available for infants birthweight <1250g with informed parental consent. Parents of all infants birth weight less than 1250g
should be approached for consent for donor milk as soon as possible after delivery.
Trophic Feeds EBM or donor milk or Enfamil Premature A+ 20 kcal/oz. (May delay trophic feeds up to 24 hr for EBM)
Nutritional Feeds EBM or donor milk or Enfamil Premature A+ 24 kcal/oz
Infants > 1500 grams Birth Weight
1500 - 1749 g
> 29 weeks
1750 - 1999 g
> 30 weeks
2000 - 2499 g
> 31 weeks
> 2500 g
> 34 weeks
Timing: Day 1 / Stable Day 1 / Stable Day 1 / Stable Day 1 / Stable
Amount/
Frequency:
3 mL q 3 hr 6 mL q 3 hr 6 mL q 3 hr 9-12 mL q 3 hr /
ad lib
Increase: 3 mL q 9 hr 3 mL q 6-9 hr 3 mL q 3-6 hr 3-6 mL q 3 hr
MacPeds Survival Guide 14-15 95
NICU NUTRITION GUIDELINES (CONTINUED)
FEEDING HUMAN MILK IN NICU
Expressed Breast Milk (EBM) + Enfamil Human Milk Fortifier
Preterm infants < 34 weeks or < 1.8-2 kg
Initiate Fortification:
When infant tolerating 100 mL/kg/d for 24 hours
Dosing:
Initially ! 1 package fortifier per 50 mL EBM
Increase ! 1 package fortifier per 25 mL EBM after 48 hours
Continue Fortification:
Until infant reaches at least 2.0-2.5 kg or is established at breastfeeding
For nutritionally compromised infants, continue fortifier until infant
reaches 2.5 3 kg or is established at breastfeeding
Note: if a baby is breastfeeding 4 times/day, and receives EBM fortified
at 1:25 the other 4 feeds with a NG tube, vitamins and minerals will
need to be reassessed as the total amount of fortifier is reduced.
MacPeds Survival Guide 14-15 96
NICU NUTRITION GUIDELINES (CONTINUED)
Formula Selection
<34 weeks or <2.0 kg birth weight
" Enfamil Premature 24 A + and reassess when close to term and
over 2200g
>34 weeks and
>2.0kg birth weight
If current weight is over 2200g,
and the birth weight was <1200
g or infant has BPD
" Enfamil Premature 24 A+
while in hospital
If the current weight is >3.0kg or
the infant is ready for discharge.
" Enfamil A + Enfacare
If current weight is over
2200-3000, and the
babys weight is
<10%ile on Fenton
growth chart
" Enfamil A +
Enfacare
If current weight
is >2200g and
above the
10%ile on
Fenton growth
chart
" Term
Formula *
" Term
Formula *
*Term Formulas: Enfamil A+, Similac Advance Nestle Goodstart
Parents may choose formula they wish to use, if no preference, use Enfamil A+ (contract)
Nutrient Composition of Fortified Human Milk / Enfamil Premature A+
per 100 mL
Nutrient Unfortified Fortified
1:50
Fortified
1:25
Enfamil
Premature
A+ 24
Energy (kcal/100 mL) 67 73 80 80
Protein g 1.3 1.85 2.4 2.4
Calcium - mmol 0.63 1.8 2.9 3.3
Phosphorus mmol 0.47 1.3 2.1 2.2
Vitamin A IU 200 675 1150 1010
Vitamin D IU 8 83 158 195
Sodium mmol 1.2 1.5 1.9 2
Potassium - mmol 1.6 1.8 2 2
Iron mg 0.09 0.81 1.53 1.46
Vitamin / Mineral Supplements using Enfamil HMF or Enfamil
Premature Formula
Vitamin D 400 units every Monday, Wednesday and Friday until weight
approximate 1500g, then discontinue
MacPeds Survival Guide 14-15 97
NICU NUTRITION GUIDELINES (CONTINUED)
TOTAL PARENTAL NUTRITION (TPN) IN NICU SUMMARY GUIDELINES
Starting TPN
Infants < 1500 g ! Start on modified TPN on admission to NICU
Neostarter (D10W + Protein [1.5g/kg] + Calcium [1mmol/kg] @ 50 cc/kg/day) on Day 1 and TPN by
24-48 hours of age
Infants > 1500 g ! Start on TPN by 48-72 hr of age if NOT expected to be enterally fed by 72 hr
Stopping TPN: TPN may be discontinued when an infant is tolerating 75% (or 120 mL/kg/d) of
full enteral feeds
Writing TPN Orders
Determine total fluid available for TPN. (Total fluid intake minus fluid for IV lines /
medications)
Determine flow rate required to provide desired amount of lipid (see summary).
The remaining fluid should be used for amino acid / dextrose solution (see summary)
Monitoring TPN (TPN) Bloodwork
For infants who have been on TPN > 48 hours; Every Monday (Week represents week of the month)
Lab \ Week ! 1 2 3 4 5
Electrolytes: Na, K x x x X x
Glucose* x x x X x
Triglycerides x x x X x
Urea / Creat x x
Ca / P x x
Bili x X x
AST / ALT x X
Albumin X
Every Thursday: electrolytes (Na, K), Glucose*, Triglycerides (until
tolerating full dose)
Trace Elements: if on long term TPN, once direct bili > 50 mmol/L
send serum for trace elements (Zn, Cu, Se , Mn) 0.6 mL
Ferritin: Infants > 6 weeks of age on TPN, check serum ferritin
before adding iron
*send urine for glucose if PCX > 10 mmol/L
MacPeds Survival Guide 14-15 98
NICU NUTRITION GUIDELINES (CONTINUED)
TOTAL PARENTAL NUTRITION (TPN) IN NICU SUMMARY GUIDELINES
(A) Macronutrients
Dextrose
Prescription
mg/kg/min g/kg/day
Initial dose 4 6 6 - 9
Average Daily Increase 0.5 - 1.0 0.7 - 1.4
Maximum dose 11 13 16 - 19
Protein
Prescription
Source: Primene 10%
g/kg/day
Initial dose * 1.5
Avg. daily increase 1.0
Maximum usual dose 3.0 - 3.5**
Energy Value: 3.4 kcal/g (0.67 kcal/mmol)
Conversions: 1 mmol = 0.2 g = 200 mg
Comments: For peripheral parenteral nutrition, the
osmolar load from dextrose should not exceed
500 mmol/L (D10W) unless necessary to maintain
euglycemia (max D12.5W)
Energy Value: 4.0 kcal/g; 16.7 kJ/g
For infants < 1500 g ! Start on modified TPN !
Neostarter (D10W + Protein + Calcium) 50 cc/kg/day on NICU
admission and TPN by 24-48 hours of age, with other IVs
**3 g/kg/day acceptable for term infants
Monitor / reassess maximum protein dose:
Renal Failure
Hepatic Failure
Elevated Serum Urea
MacPeds Survival Guide 14-15 99
NICU NUTRITION GUIDELINES (CONTINUED)
TOTAL PARENTAL NUTRITION (TPN) IN NICU SUMMARY GUIDELINES
(A) Macronutrients (Continued)
Lipid
Prescription
Source: Clinoleic 20%
Full PN
< 50% PN
Initial Dose (g/kg/day) By 24-48 hr of age
0.5 - 1.0 g/kg/day
Average Daily Increase
(g/kg/day)
0.5-1 g/kg/d
Maximum Dose (1)
(g/kg/day)
2.5-3.5 g/kg/day 1-2 g/kg/day
Energy Value: 20% - 2 kcal / mL; 8.4 kJ / mL
Conversions: 20% - 0.2 g fat / mL
Cautions:
For infants with worsening acute lung disease or hyperbilirubinemia (unconjugated),
Hold lipid at 0.5 - 1.0 g/kg/day until clinical condition improves
Sepsis - decrease lipid to 1 g/kg/day for first 24 - 48 hr and then increase as tolerated to full rates
Monitor / reassess:
Triglycerides (TG) every Tuesday and Friday until tolerating maximum dose, then every Tuesday
Interpretation: (<2mmol//L is acceptable)
Consider lipid restriction for infants with cholestasis. Consider SMOF lipid for infants with Short Bowel
Syndrome. If if conjugated bilirubin consistently above 100 mmol/L, consider Omegavan (Use requires
approval for special access from Health Canada)
MacPeds Survival Guide 14-15 100
(1) Actual requirements for sodium may be
significantly higher in the first two weeks of life,
depending on urinary losses.
(2) Due to the limits of solubility of calcium and
phosphorus in amino acid solutions, the
maximum dose of 15 mmol of calcium and
phosphorus per litre of amino acid solution can
only be attained if the total amino acid
concentration is 30 g/L or higher. Otherwise,
precipitation of calcium and phosphorus may
occur.
Caution: do not add phosphorus to TPN unless
there is at least 1 g/kg amino acids added to the
solution. Normal molar ratio of Ca:P is 1:1. Use
caution if unequal amounts of calcium and
phosphorus added to TPN solution.
NICU NUTRITION GUIDELINES (CONTINUED)
TOTAL PARENTAL NUTRITION (TPN) IN NICU SUMMARY GUIDELINES
(B) Micronutrients
Minerals (Maintenance intakes for stable, growing infants)
Usual Dose
(mmol/kg/day)
Term Infants > 3kg
(mmol/kg/day)
Sodium 2 - 4 (1) 2
Potassium 2 2
Magnesium 0.2 0.2
Calcium 1 - 1.5 (2) 1
Phosphorus 1 - 1.5 (2) 1
Vitamins
Source: MVI Pediatric (MVI Ped)
Dosage: Initiate at 24-48 hr of age <1kg- 1.5ml
1-3kg- 3.25ml
>3kg- 5ml
Trace Elements
Source:
mcg / mL ! Zinc Copper Selenium Chromium Manganese Iodine Dose
Neo Trace Element Mix 425 19 2 0.2 1 1 1 mL/kg up 3 mL
Liver Mix* 300 10 2 0.2 1 1 mL/kg up 10 mL
*To be used when direct bilirubin > 50 mmol/L; Send blood for trace elements when changed to Liver Mix
Iron : 0.1-0.2 mg/kg (Initiate at 6 weeks of age for infants on TPN if ferritin <500)
MacPeds Survival Guide 14-15 101
NICU NUTRITION GUIDELINES (CONTINUED)
VITAMIN/MINERAL SUPPLEMENTS IN NICU SUMMARY GUIDELINES
Vitamins Prescription
Feeding Tri-Vi-Sol D-Drops
Preterm Infants Unfortified EBM 0.5 mL BID none
In Hospital Fortified (1:25) EBM None 400 units MWF
until 1500 g
(< 2000 grams) Enfamil Prem 24 None 400 units MWF
Until 1500 g
Term Infant EBM none 400 units daily
Formula none none
Preterm Infants
After
Discharge Home
Human Milk or
Term Infant Formula
Intake < 800 mL/day 0.5-1.0 mL daily
Intake > 800 mL/day - none
None
1.0 mL OD
(human milk only)
1.0 mL Tri-Vi-Sol contains: 10 ug (400 IU) Vitamin D, 450 ug (1500 IU) Vitamin A, 30 mg Vitamin C
1 drop D drops contains : 400 IU vitamin D
Iron (Fe) Prescription: Ferrous Sulfate (1.0 mL = 15 mg elemental Fe)
Preterm infants in hospital @ 4-6 weeks of age: 0.1 ml 1.5 mg Iron
Doses Available: 0.2 ml 3 mg Iron
0.3 ml 4.5 mg Iron
Preterm Infants after discharge Prescription: Fer-In-Sol (Mead Johnson) (1.0 mL = 15 mg elemental Fe)
(See Notes below) < 3-4 kg 0.5 mL OD (7.5 mg Iron)
> 3-4 kg 1.0 mL OD (15 mg Iron)
1. P-RNI for iron: 2-4 mg/kg/day up to max. 15 mg elemental iron given as ferrous sulfate supplement or iron fortified formula.
(Birth Weight < 1 kg: 3-4 mg/kg/day; > 1 kg: 2-3 mg/kg/day)
2. Prescription amounts above are given as elemental iron (check dosage on product used). (1 mg elemental iron =5mg ferrous
sulfate) Note- Preterm formula (Enfamil Premature A+ 24) and Enfamil HMF are iron fortified. Dose of iron should be adjusted based
on iron received from feeds
MacPeds Survival Guide 14-15 102
GBS status:
UNKNOWN
GBS status:
NEGATIVE
No action
required for
newborn
Yes
No
Yes
Mother received at
least one dose greater
than or equal to 4 h
prior to delivery?
No action
required for
newborn
No
Are there any
MATERNAL RISK FACTORS?
Rupture of membranes (ROM)
greater than 18 h
Gestational age less than 37 wks
GBS bacteriuria in current
pregnancy
Previous infant with invasive GBS
infection
Maternal fever greater than 38
o
C
Yes
GBS status:
POSITIVE
MATERNAL CONSIDERATIONS: Women with GBS bacteriuria in the current pregnancy or who had a prior newborn with invasive GBS disease do not
need to be screened and require intrapartum prophylaxis. Screening of all other women at 35 to 37 weeks gestation, including women planning elective
CS is recommended. Antepartum treatment of GBS colonization is not justified with the exception of urinary group B streptococcal colony counts greater
than 100 000 CFU/mL . For women with positive GBS and prelabour rupture of membranes at term, induction of labour is recommended. At any point,
the MRP may consider an ID (Infectious Diseases) physician consult. NEWBORN: No protocol prevents all GBS morbidity or mortality. Ongoing
newborn assessment and timely interventions should not be limited by these guidelines. If at any point the newborn shows signs of sepsis (i) Notify
the MRP (ii) Obtain a Pediatric consult for a full diagnostic evaluation and initiation of antibiotic therapy. If a second CBC is to be drawn, consider
ordering a CRP (C-Reactive Protein).
Algorithm - Group B Streptococcus (GBS) Management Guidelines
Revised Sept 18 2013 LY
Mother has
received
GBS
Prophylaxis
Antibiotics
Mother:
has laboured (latent or active)
or
has ruptured membranes
Mother:
Mother:
is delivered by elective C/S
has not laboured
has not ruptured membranes
regardless of GBS status
2
0
0
9
Q
u
e
e
n
s
P
r
i
n
t
e
r
f
o
r
O
n
t
a
r
i
o
MacPeds Survival Guide 14-15 189
MacPeds Survival Guide 14-15 190